Case management: a week in the life of a clinical case management team

Case management models and the care programme approach: how to make the CPA effective and credible

The care programme approach (CPA), a form of case management, is a key mental health policy in England. Yet after over 10 years, it remains poorly and unevenly implemented with few benefits for service users, carers or mental health staff. This paper reviews the wider literature on case management and identifies and considers the principal models that might have informed the development of the CPA. After discussing the evidence for each of the clinical, strengths, intensive and assertive case management models, the paper identifies the key components that appear to be central to effective case management across these models. These components are then considered in relation to the CPA. It is argued that the CPA has been undermined by a failure to incorporate and build on certain important features of the major models of case management. The paper concludes by suggesting the key developments required to make the CPA more effective and to underpin the policy with a unifying philosophy while endorsing it with much needed credibility among both clinicians and service users.

The case management practices of community mental health nurses: 'Doing the best we can'

This paper reports findings from an investigation into the case management practices of a group of community mental health nurses in metropolitan South Australia. Such practices have received little attention in the Australian literature to date. These nurses collectively organized their clients into four informal groups in order to manage the demands of heavy workloads. The implications of these findings and recommendations for further evaluative investigations into the nature of case management practices are discussed.

Effects of case-load size on the process of care of patients with severe psychotic illness. Report from the UK700 trial

BACKGROUND

Studies of intensive case management (ICM) for patients with psychotic illnesses have produced conflicting results in terms of outcome. Negative results have sometimes been attributed to a failure to deliver differing patterns of care.

AIMS

To test whether the actual care delivered in a randomised clinical trial of ICM v. standard case management (the UK700 trial) differed significantly.

METHOD

Data on 545 patients' care were collected over 2 years. All patient contacts and all other patient-centred interventions (e.g. telephone calls, carer contacts) of over 15 minutes were prospectively recorded. Rates and distributions of these interventions were compared.

RESULTS

Contact frequency was more than doubled in the ICM group. There were proportionately more failed contacts and carer contacts but there was no difference in the average length of individual contacts or the proportion of contacts in the patients' homes.

CONCLUSIONS

The failure to demonstrate outcome differences in the UK700 study is not due to a failure to vary the treatment process. UK standard care contains many of the characteristics of assertive outreach services and differences in outcome may require that greater attention be paid to delivering evidence-based interventions.

Subjective quality of life, psychopathology, satisfaction with care and insight: an exploratory study

We have investigated the determinants of global subjective quality of life (GSQOL) using data from a controlled trial of intensive case management for the severely mentally ill. In a multiple regression analysis depression, age, objective quality of life and domain-specific quality of life together explained 59% of the variance in GSQOL. GSQOL was not significantly correlated with measures of positive psychotic symptomatology, insight or attitudes to treatment but was correlated with satisfaction with care (r = .21, p = .011). Change in GSQOL over 18 months was correlated with change in domain-specific quality of life (r = -.45, p = .002) and depression (r = -.43, p = .01): multiple regression analysis confirmed that both variables had an independent effect on change in GSQOL.

Intensive case management for the severely mentally ill. Controlled trial

BACKGROUND

The aim was to compare the efficacy of intensive clinical case management (ICM) with standard community care in the management of 'hard to treat' patients with a severe mental illness.

METHOD

A randomised controlled trial was carried out in East Lambeth, a deprived area of inner London. Seventy people with psychosis designated as 'hard to treat' by referring teams were included; 35 were randomised to ICM (case load eight patients per worker), and 35 to standard care, which offered follow-up by a community psychiatric nursing service (30 patients per worker). Outcome measures were admissions and hospital bed utilisation; contact with services; symptomatology; social behaviour; social functioning; quality of life; patients' satisfaction with care at 9 and 18 months.

RESULTS

There were no differences in patients' symptoms, social behaviour or social functioning. Quality of life was significantly improved in patients receiving ICM at 9 months. Satisfaction with care was significantly greater among case-managed patients. All ICM patients remained in contact with services throughout the study, while six control patients were refusing all contact with services at 18 months.

CONCLUSIONS

ICM failed to improve the clinical outcome of 'hard to treat' patients. The service was successful in maintaining contact with patients, was greatly appreciated and had a positive effect on their perceived quality of life.