Pathways of recovery: preventing further episodes of mental illness (monograph)
Many people with a history of mental illness have a complex array of needs that must be considered. Case management is one of the major types of community aftercare that is used to provide ongoing management of chronic or recurring illness. Active case management is especially important for people who have been repeatedly hospitalised for mental illness. Too often these people experience a 'revolving door', a recurring pattern of discharge and re-admission to hospital because they are not adequately supported in the community. The more chronic and disabling the experience of mental illness, the more a case management approach to continuing care is required for people with mental illness, and their families and carers.
There are many different models of case management (Chamberlin & Rapp 1991), but the major approaches are assertive community treatment teams and case workers with individual case loads. In assertive community treatment, services are usually provided by a community team on an ongoing and intensive basis (Bond et al 1990). The effectiveness of the assertive community treatment approach in reducing relapse in terms of hospitalisation has generally been established (eg, Bond et al 1990, Chamberlin & Rapp 1991, Solomon 1992).
Most case management programs in mental health, however, typically involve a single case manager working with a consumer. The role of the case manager is to undertake assessment, monitoring, planning, advocacy and linking of the consumer with rehabilitation and support services (Intagliata, 1982). Its function is clearly illness management and relapse prevention.
Evaluations of the effectiveness of individual case management have been somewhat contradictory (eg, Borland, McRae & Lycan 1989; Goering et al 1988; Nelson & Sadeler 1995). Importantly, where significant reductions in hospitalisation have been found the staff to consumer ratio has been 1:9-20. Studies that have not reported reductions in hospitalisation have reported higher caseloads, and it has been argued that in programs where the ratio is 1:20-40, case managers do not have sufficient time to provide the individualised support that is required to help people adapt to community living (Harris & Bergman 1988). There is also wide variation in the philosophy and practice of case management, and the relationship between the case manager and consumer is seen as fundamental to success. The principles of effective case management have been extensively studied, and are presented in Table 3 as they apply for mental health services.
There is a great deal of unmet need in Australia for case management (Groom et al 2003). The lack of a case manager was mentioned repeatedly in the consultations as a major barrier to recovery. This is even more pronounced in regional, rural and remote areas, and there were many stories of people being discharged from hospital with no discharge planning and no aftercare. Even in regions where case management models were available, often the case manager had too large a caseload to provide effective relapse prevention.
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I currently have 40 people on my list. My understanding is that best practice is about 12 clients. With 40 I can barely get around to seeing them every 2 weeks. I certainly don't have the time to put in place all the psychosocial supports that they need, even if they were available. —Case manager
The majority of people who have been seriously affected by mental illness do not have a case manager. Consequently, the functions of the case manager fall to other people-the consumer him/herself, family and carers, and general practice. Notably, many carers find their 'case management' role a significant burden and feel that they are completely unsupported in this role: they do not have access to resources, supports, services or even appropriate information about their family member. Carers feel that they are forced to assume a case management role, without the authority, skills or resources to do so. While case management is not a panacea, there is an urgent need for more case management within the mental health system, to ensure that people seriously affected by mental illness are connected with the clinical and psychosocial supports that they need to remain in the community.
I am the only case manager my son has and they don't even tell me when he is discharged from hospital. All of a sudden he is back at home and I have to manage as best I can, which is not good enough. —Carer
Table 3. Principles of effective case managementTable 3 is presented as a list in this HTML version for accessibility reasons. It is presented as a table in the PDF version.
- Case managers should deliver as much of the "help" or service as possible, rather than making referrals to multiple formal services.
- Natural community resources are the primary partners (eg, landlords, employers, teachers, art clubs, etc).
- Work is in the community.
- Both individual and team case management works.
- Case managers have primary responsibility for a person's services.
- Case managers can be para-professionals. Supervisors should be experienced and fully credentialed.
- Caseload size should be small enough to allow for a relative high frequency of contact (no more than 20:1).
- Case management service should be time-unlimited, if necessary.
- People need access to familiar persons 24 hours a day, 7 days a week.
- Case managers should foster choice.
Source: Rapp & Goscha (2004)