Case Management in Mental Health Services

Charlotte Sanborn

• Publisher: Routledge
• Year: 2014
• eBook ISBN: 9781317735045
• Topic: Medicine
• Subtopic: Medical Theory, Practice & Reference

An invaluable resource on the basic principles of case management, including the necessary guidelines for practice.

Part I

WHY CASE MANAGEMENT?

Chapter 1

CASE MANAGEMENT: THE ESSENTIAL SERVICE

Gary Miller, M.D.

We have heard a great deal about case management during the past four or five years. And it is no accident that our renewed interest in this essentially old-fashioned approach to service has coincided with the emergence of issues of critical nationwide significance in the mental health field. Few are now unaware of the plight of thousands of mentally handicapped people struggling to survive outside of institutions in our communities, and of the fact that our present service delivery system has not been effective in meeting the basic and special needs of many of these people.

During the late 1960s and the early 1970s, mental health workers placed great emphasis on moving people from the institutional to the community setting in the belief that patients would somehow benefit merely by virtue of their being “in the community.” Reduction of institutional census was a major goal for state mental health systems and individual state hospitals. While the newly established community mental health centers made some inroads into the problems of chronic mental patients, little thought was given in those days by state agencies or the community programs as to whether and how communities could meet the overwhelming needs of these people who had spent many years of their lives in an institution which had demanded little of them and had fostered childlike dependency and atrophy of basic living skills. We now know that many of these individuals did not fare very well.

In January 1977, the General Accounting Office report on deinstitutionalization¹ called the attention of Congress to the tragedy of mentally disabled persons who had slipped through the cracks between the myriad of HEW agencies and their state and local counterparts. The President’s Commission on Mental Health reported to the President in 1978 on the scope of the problem:

Time and again we have learned—from testimony, from inquiries, and from the reports of special task panels—of people with chronic mental disabilities who have been released from hospitals but who do not have the basic necessities of life. They lack adequate food, clothing or shelter. We have heard of woefully inadequate follow-up mental health and general medical care. And we have seen evidence that half the people released from large mental hospitals are being readmitted within a year of discharge. While not every individual can be treated within the community, many of the readmissions to the state hospitals could have been avoided if comprehensive assistance had existed within their communities.²

The census of institutions for the mentally retarded did not begin to fall as early, nor did it fall as rapidly, as that of state mental hospitals, but the trend is clearly in the direction of community care for most mentally retarded people.³ Aside from some differences in nomenclature, e.g., substitution of the term normalization for deinstitutionalization, and of habilitation for rehabilitation, the needs and problems of the mentally retarded in the community are entirely comparable to those of the chronically mentally ill. As in the case of the chronically mentally ill, there are many mentally retarded people whose needs are not being met.³

The task panel on organization and structure of the President’s Commission on Mental Health emphasized that the problems of deinstitutionalization are directly attributable to a lack of coordination and continuity in the delivery system:

Panel members unanimously agreed that mental health services, even after 14 years following passage of the Community Mental Health Centers Act, were still fragmented, poorly coordinated, provided a narrow range of services which were often inappropriate to communities served, were plagued by the absence of continuity between state and local problems, and lacked a systematic approach to service delivery.⁴

In a similar vein, the General Accounting Office reported that “a coordinated system of care for the mentally ill through the CMHC program remains a goal rather than reality.”¹

In the light of these recent observations of the CMHC program, we should be aware that fragmentation and lack of coordination are not recently discovered problems, nor were they unanticipated in the early days of the community mental health movement. An analysis of then existing community mental health models published in 1964 by the Joint Information Service of the American Psychiatric Association and the National Association for Mental Health at the outset of the federal CMHC program specifically addressed the problem:

The mentally ill … need a complete range of service if they are to have the best chance for recovery. But even in communities with highly developed services, individual agencies have tended to operate in isolation. As a consequence, there have been many serious gaps in service. Furthermore, it has been necessary for an individual to undergo a complete and separate interview and evaluation at each agency whose service he sought—a procedure wasteful of already inadequate professional time and disruptive and discouraging to the patient. It has also resulted in a given patient’s being treated by a succession of different people.⁵

It was expected in 1964 that the new CMHC program would “coordinate existing programs … establish the missing elements in a single comprehensive service and … provide whatever … treatment is needed at the time it is needed and within the community where the patient lives. ”⁵

While the community mental health centers have greatly increased the variety and volume of service in hundreds of communities of the United States, the promise of 1964 has not been fulfilled, especially for those with chronic disability; weakened or absent family ties; excessive dependency needs; and a limited repertoire of personal, social, and vocational skills. It seems that the roster of essential services called for by the NIMH model of the community mental health center has lacked one key essential service.

Today, case management is recognized as one of the most essential services, if not the essential service, in community programs. It is viewed as a means of overcoming the complexity and fragmentation of our service system and of reaching the inadequately served chronically and severely disabled population.⁶–¹¹ Turner and TenHoor emphasize that “there must be a single person (or team) at the client level responsible for remaining in touch with the client on a continuing basis regardless of how many agencies get involved. ”⁸ According to the Task Panel on Deinstitutionalization, Rehabilitation and Long-Term Care of the President’s Commission on Mental Health, “Strategies focused solely on organizations are not enough. A human link is required. A case manager can provide this link and assist in assuring continuity of care and a coordinated program of services.”¹² The President’s Commission on Mental Health accepted the recommendations of the Task Panel concerning case management and in turn recommended to the President that “state mental health authorities develop a case management system for each geographic service area within the state. ”² That should be accomplished, according to the Commission, through designation by the state mental health authority of one agency in each area to assume responsibility for case managing the chronically mentally ill of that area.² A similar mandate with respect to mentally retarded and other developmentally disabled persons issues from the current federal developmental disabilities legislation which establishes case management as a priority service.¹³

This degree of emphasis on case management is justified by evidence that it can work well. Its dramatic effectiveness in some settings suggests even that it may have been the missing element in the delivery system, the one “essential service” without which other resources and staff cannot successfully meet the needs of the more severely handicapped person.

Six years of research conducted by Leonard Stein, Mary Ann Test, and their colleagues in Madison, Wisconsin have established the effectiveness of case management in meeting the survival requirements of severely disabled and highly symptomatic people in a community setting,⁷.¹⁴.¹⁵ Stein and Test have also shown that case management services must be maintained on an indefinite basis, for if the case managers are withdrawn from even relatively well-adjusted mental patients, their relapse and rehospitalization rates will rise, eventually approaching those of non-case managed controls.¹⁴

A federally funded project in Virginia, the Services Integration for Deinstitutionalization (SID) Project, demonstrated in both an urban and rural setting that case managers (called broker-advocates) can be effective in meeting the needs of chronic mental patients in the community.¹⁶

Weinman and Kleiner’s case managers (called enablers) were successful in improving the social performance, self-esteem, and community tenure of former state hospital patients.¹⁰

Fountain House in New York City, which can be viewed as a case management program operated by former state hospital patients, has also been demonstrated to be effective in maintaining chronically disabled persons for long periods of time in the community.¹⁷

Whatever else we do to serve the severely disabled, chronically mentally ill, or mentally retarded person in the community, the evidence suggests that case management is a necessary ingredient. In the view of Norman Lourie, case management “is a vital, perhaps the most primary, device in mana...

Table of contents

• Cover Page
• Half Title page
• Title Page
• Copyright Page
• Contents
• Foreword
• List of Contributors
• Acknowledgments
• Introduction
• Why Case Management?
• Case Management: the Essential Service
• Case Management: a Remedy For Problems of Community Care
• Case Management: Implications and Issues
• Systems/Organizational issues
• Organizational Issues And Case Management
• Client-Based Program Administration
• Legal/Ethical Issues
• Clients' Rights in a Case Management System
• Ethics of Case Management
• Training Case Managers
• The Experience in New York State
• Training Case Managers for the Developmental Disabilities System
• Rehabilitation
• A Process Within a System
• Case Studies
• Developmental Disabilities Programs
• Mental Health Programs
• Welfare Programs
• Summary
• Case Management in Mental Health Services
• Case Management: a Summary
• Bibliography
• States With Case Management Programs