Handbook of Community Psychiatry || Case Management and Assertive Community Treatment

293H.L. McQuistion et al. (eds.), Handbook of Community Psychiatry, DOI 10.1007/978-1-4614-3149-7_24, © Springer Science+Business Media, LLC 2012

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Introduction

For nearly 50 years, case management has been the keystone of community mental health care for people with serious mental illnesses, essential for optimal treatment and support. Speci fi c mod-els of case management have emerged and evolved in response to inadequacies in systems of care at any particular time. Many of these models have been further re fi ned as part of the evidence-based practices movement in an attempt to bind together an array of effective services called evidence-based practices. But much has changed in the past few years that will challenge the future development and effectiveness of case management. Basic social supports have eroded. People with mental illnesses have been shunted into the criminal justice system. Psychiatrists in community mental health centers have been mar-ginalized. Medical comorbidities and early mor-tality have become salient and have probably increased. Insurance payments to the pharmaceu-tical industry and to managed care companies have increased while payments for psychosocial

supports have decreased. And at the same time that services have deteriorated, expectations have increased!

In this chapter, we trace the history of mental health case management, review the evidence for speci fi c models of case management, enumerate general principles of effective case management, and discuss the current challenges regarding case management in a rapidly changing health care environment.

History

During the era when people with psychiatric disabilities spent considerable periods of their lives in asylums and psychiatric hospitals, all the available services were under one roof. Deinstitutionalization began in the 1950s despite the dearth of community-based services. Subsequently, the Community Mental Health Centers Act of 1963 established local mental health service providers throughout the United States. A limited array of services was mandated with an emphasis on counseling, partial hospital-ization/day treatment, and medication manage-ment. Many people discharged from the hospital lived in urban ghettoes or with overwhelmed families. The narrow range of supports was clearly inadequate to sustain a person in the com-munity, and the “revolving door” of psychiatric hospitalization became the de facto course of treatment for many. Furthermore, people living in the community were poor and lonely, lacked

R. J. Goscha , PhD (*) • C. A. Rapp , PhD Of fi ce of Mental Health Research and Training , School of Social Welfare, University of Kansas , 1545 Lilac Lane , Lawrence , KS 66044 , USA e-mail: [email protected]

G. R. Bond , PhD • R. E. Drake , MD, PhD Department of Psychiatry , Dartmouth Psychiatric Research Center, Dartmouth Medical School , Concord , NH , USA

Case Management and Assertive Community Treatment

Richard J. Goscha , Charles A. Rapp , Gary R. Bond , and Robert E. Drake

294 R.J. Goscha et al.

decent housing, and had few opportunities for meaningful activity (Draine et al. 2002 ) .

The Community Support Program (CSP), initiated by NIMH in 1977, sought to increase the support services available to people with psychi-atric disabilities. CSP recommended and helped establish a wide range of support services, including crisis stabilization services, vocational services, various forms of housing, daytime and evening activities, support to families, and assis-tance in accessing entitlements. This range of services, while badly needed, added considerable complexity for clients and families to arrange access and coordinate efforts often from multiple organizations and service providers. Case man-agement was included in CSP to assure the con-tinuous availability of individualized assistance (Turner and TenHoor 1978 ) .

The earliest model of case management, the broker model, sought to coordinate care by link-ing clients to services based on an assessment of need; services included planning, monitoring, and advocacy (Intagliata 1982 ) . A single entity would be responsible for organizing access to needed services from a fragmented and complex service system—largely an administrative func-tion. The distinguishing characteristic of the bro-ker model was that its central purpose and method was to link people with formal mental health services and entitlements (Curtis et al. 1992 ) . The assumption was that once services were accessed a person would be able to live more independently and their quality of life would improve. In the early 1980s, Medicaid began reimbursing states for broker model case man-agement (Hogan 1999 ) .

Thus, case management was originally intended to coordinate care through referrals to needed services. But the broker model was based on the faulty premise that needed services were in fact available in the community. Its disappoint-ing results (see section “Research on Case Management”) were, in part, due to the poor quality and effectiveness of available services. Evidence-based practices, interventions with the most robust empirical support, were not available in most settings. Even today, availability and access are minimal (Drake and Essock 2009 ) .

Another weakness in the broker model was the requirement that clients engage with a complex and bureaucratic service system. Again, engage-ment remains a huge barrier to effective treat-ment today (Kreyenbuhl et al. 2009 ) .

In contrast to the broker model, several more clinical approaches developed in which case managers built relationships with clients and directly delivered some services while coordi-nating others. The broker function became but one component of a more complete version of case management. Two approaches, Assertive Community Treatment (ACT) and Intensive Case Management (ICM), focused primarily on structural aspects of the service model, such as low caseloads, outreach mode of service deliv-ery, etc. ACT has been speci fi ed in several manuals (Allness and Knoedler 2003 ; Test and Stein 1976 ) .

ACT and ICM were designed for clients with high use of inpatient and emergency room ser-vices or other high-need target populations (Surles and McGurrin 1987 ) . Although ICM does not have a single agreed-upon de fi nition, some common features include the following: low caseloads; assertive outreach including home and community visits; tangible supports for income support, housing, transportation, and activities of daily living; and a focus on preventing unneces-sary psychiatric hospitalizations (Schaedle and Epstein 2000 ) . While similar to ACT, ICM does not prescribe the team structure and shared case-loads, nor does it even necessarily involve a team.

Clinical Case Management and Rehabilitation Case Management further elaborated the case manager’s clinical activities. (In both models, case managers also brokered some services.) Clinical Case Management emphasized individ-ual psychotherapy or counseling, living skills training, and psychoeducation (Kanter 1989, 1996 ; Walsh 2000 ) ; Rehabilitation Case Management stressed teaching living skills (Farkas and Anthony 1993 ) .

Another direct service model, the Strengths Model, emerged in the mid-1980s as an antidote to traditional de fi cit-based approaches. The Strengths Model contained structural and clinical

29524 Case Management and Assertive Community Treatment

prescriptions as well as standards for supervision of case managers (e.g., review of practice tools, feedback, fi eld mentoring). Structural features included caseload size not to exceed 20:1, use of group supervision, and outreach for service delivery. Clinical components included speci fi c tools and methods to help clients set meaningful and important recovery goals, and to emphasize the strengths of the client and the environment in order to achieve these goals. In contrast to both Clinical and Rehabilitation models with their focus on changing the individual (e.g., gaining insight, learning skills), the Strengths Model focuses on fi nding, creating, and supporting opportunities for people that match their goals and aspirations (Rapp and Goscha 2006 ) .

Research on Case Management

Broker Model

The broker model has failed the test of evidence-based practice. At least nine experimental or quasi-experimental studies of the broker model have been published (Bigelow and Young 1991 ; Curtis et al. 1992 ; Edwards et al. 1991 ; Franklin et al. 1987 ; Hornstra et al. 1993 ; Jerrell and Ridgely 1995 ; Lehman et al. 1994 ; Muller 1981 ; Rossler et al. 1992 ) . These studies have generally found increased use of psychiatric hospitaliza-tion (Curtis et al. 1992 ; Franklin et al. 1987 ) and no differences in quality of life (Curtis et al. 1992 ; Lehman et al. 1994 ) . Eight of the nine studies found no advantages for the broker model.

Assertive Community Treatment

Over the last three decades, ACT has proven to be a robust treatment model for people with severe mental illness. The model’s features have been clearly described (McGrew and Bond 1995 ) and measured by a fi delity scale (Teague et al. 1998 ) . In the United States, ACT has been identi fi ed as an evidence-based practice by expert panels (Drake et al. 2001 ; Kreyenbuhl et al. 2010 ) , endorsed in federal reports (New Freedom

Commission on Mental Health 2003 ; Surgeon General 2000 ) , and vigorously advocated by the National Alliance on Mental Illness (Allness and Knoedler 2003 ) .

ACT has also been extensively studied. A 2001 review located 25 randomized controlled trials (Bond et al. 2001 ) ; probably at least that number of studies have been conducted since then. Of the many relevant reviews conducted since 1998 (Baronet and Gerber 1998 ; Bedell et al. 2000 ; Bond et al. 2001 ; Burns et al. 2007 ; Coldwell and Bender 2007 ; Corrigan et al. 2008 ; Gorey et al. 1998 ; Herdelin and Scott 1999 ; Latimer 1999 ; Marshall and Creed 2000 ; Mueser et al. 1998 ; Nelson et al. 2007 ; Scott and Dixon 1995 ; Smith and Newton 2007 ; Ziguras and Stuart 2000 ) , some have focused speci fi cally on ACT, whereas other reviews have broadened their focus to include any ICM model. Despite this heterogene-ity, the reviews generally agreed on several key fi ndings.

First, ACT increases community tenure for clients with extensive psychiatric hospitaliza-tions. Second, ACT improves residential outcomes, though the speci fi c measures in this domain have been diverse and have included reduction in homelessness, residential stability, independence of housing arrangement, and other indicators. ACT is particularly effective for clients with the high rates of hospitalization (Burns et al. 2007 ) and for those who have been homeless (Coldwell and Bender 2007 ) . Third, ACT sustains engagement in treatment (Bond et al. 1995 ) . Fourth, ACT clients and their fami-lies express higher satisfaction with services (Mueser et al. 1998 ) . Fifth, ACT enhances self-reported quality of life (Bond et al. 2001 ) .

The evidence for ACT is negative or mixed on a number of other domains, including symptoms, substance use, employment, criminal justice involvement, and social functioning (e.g., Bond et al. 2001 ; Mueser et al. 1998 ) . To improve these other outcomes, ACT must be augmented with interventions speci fi c to these domains. For example, to address co-occurring substance use disorder, ACT teams should employ substance abuse specialists and incorporate evidence-based principles of integrated dual disorders treatment


(Drake et al. 2008 ) . Similarly, ACT should incor-porate supported employment to improve employment outcomes (Bond et al. 2008 ) .

ACT has recently been modi fi ed in several ways. Because increasing numbers of clients with psychiatric disabilities are now involved in cor-rectional systems, ACT has been used to serve this population and to reduce recidivism. Early ACT studies generally found no impact or nega-tive outcomes in this area. A newer forensic ACT model (Lamberti et al. 2004 ; Morrissey et al. 2007 ) has minimal research (Cusack et al. 2010 ) . Historically, state mental health authorities promoted ACT in the interests of reducing insti-tutional care (Mowbray et al. 1997 ) . Another change has been to emphasize the recovery orientation of ACT (Salyers and Tsemberis 2007 ) , for example, by augmenting ACT teams with Illness Management and Recovery (IMR) services (Mueser et al. 2002 ) , another evidence-based practice. A recent study combining ACT and IMR yielded inconclusive results (Salyers et al. 2010 ) .

Given the proliferation of case management services labeled as ACT but departing from the original model, several research groups have developed fi delity scales (McGrew et al. 1994 ; Teague et al. 1995 ) . The most widely used ACT fi delity scale is the DACTS (Teague et al. 1998 ) . A recent update of that scale is more comprehen-sive (Bjorklund et al. 2009 ) . Fidelity to the ACT model is modestly associated with better out-comes (Bond et al. 2001 ; Burns et al. 2007 ; Latimer 1999 ) .

In contrast to the positive reviews of ACT in the United States, researchers outside the United States have criticized the ACT model (Burns 2000 ; King 2006 ; van Veldhuizen 2007 ) . In the UK, for example, several large ACT trials yielded null fi ndings, leading British researchers to question the effectiveness of ACT when com-pared to competent standard services. King ( 2006 ) noted that much of the evidence for ACT (and ICM) is out of date, and some recent ACT trials have found no differences compared to standard services in high-resource states (Drake et al. 1998 ) . Van Veldhuizen ( 2007 ) developed and evaluated a hybrid model of ACT prompted

by the inadequacies of the standard ACT model for rural settings. Another concern regarding ACT has been the lack of clear plans to transfer clients over time, based on the original ACT prescription of lifetime services, which limits the capacity of ACT to admit new clients. These concerns remind us of the need to continuously reevaluate and to modify service models to respond to new conditions and populations, and to challenge untested assumptions (Bond and Drake 2007 ) .

Strengths Model

Besides ACT, the most widely studied case man-agement approach is the Strengths Model. Nine studies have tested the effectiveness of the Strengths Model with people with psychiatric disabilities. Four of the studies employed experi-mental or quasi-experimental designs (Modrcin et al. 1988 ; Macias et al. 1994, 1997 ; Stanard 1999 ) , and fi ve used nonexperimental methods (Rapp and Chamberlain 1985 ; Rapp and Wintersteen 1989 ; Ryan et al. 1994 ; Kisthardt 1993 ; Barry et al. 2003 ) . These studies produced positive outcomes in the areas of hospitalizations, housing, employment, reduced symptoms, leisure time, social support, and family burden.

In the four experimental studies, positive outcomes signi fi cantly outweighed the outcomes in which no signi fi cant difference was reported. In none of the studies did clients receiving Strengths Model case management do worse. The results have also been remarkably consistent across settings and within studies. Three of the studies had multiple sites with different case managers, supervisors, and af fi liations, with a total of 15 different agencies.

The two outcome areas in which results have been consistently positive are reduction in symp-toms and enhanced quality of community life. All three studies assessing symptom outcomes reported statistically signi fi cant differences favor-ing the Strengths Model. This included fi ndings that people receiving Strengths Model case management reported fewer problems with mood and thoughts, and greater stress tolerance and


psychological well-being than the control groups. In one study that compared ACT and the Strengths Model, no differences were found in hospitaliza-tion and social functioning but statistically signi fi cant differences favoring the Strengths Model were found for symptomatology (Barry et al. 2003 ) .

Although the studies used a variety of mea-sures (e.g., increased leisure time in the commu-nity, enhanced skills for successful community living, increased social supports, decreased social isolation, and increased quality of life), people receiving Strengths Model case management had enhanced levels of competence and involvement in community living. Eight of the nine studies using these types of measures reported statisti-cally signi fi cant positive outcomes.

Other outcomes that seem to be strong indica-tors of the effectiveness of Strengths Model case management include reduced hospitalization (three out of six studies showing positive outcomes), vocational (two out of two showing positive outcomes), and housing (two out of two showing positive outcomes).

The research on Strengths Model case man-agement is suggestive of its effectiveness. On the downside, the research is limited to two experi-mental, two quasi-experimental, and fi ve nonex-perimental studies. The size of the samples in three of the experimental studies was small. The measures used across studies varied and questions have been raised about many of these measures (Chamberlain and Rapp 1991 ) .

Other Case Management Models

There have been no studies of the effectiveness of clinical case management. The effectiveness of the Rehabilitation model is limited to one quasi-experimental study (Goering et al. 1988 ) . An appraisal of the effectiveness of ICM is com-plicated by the lack of a standard, commonly accepted meaning of the term, “intensive case management.” Some reviewers have used ICM as a broader rubric to include ACT as well as other variants of ICM. On closer examination, the majority of studies commonly included in

these reviews are in fact ACT studies. To our knowledge, no review has expressly examined non-ACT ICM studies as a subcategory. Moreover, no rigorous head–head comparisons between ACT and ICM have been reported in the literature.

Barrier to the Effectiveness of Case Management

Today multiple changes in society and in the health care system impinge on and seriously chal-lenge effective case management. To curtail costs, case management is often managed itself by managed care agencies. These organizations provide pressures for ef fi ciency, documentation, and reimbursable service units and thereby make it dif fi cult for case managers to perform many effective services, such as outreach, helping peo-ple fi nd jobs, and building relationships slowly with people who have dif fi culty trusting others. Medicaid is the primary funding source for community mental health services including case management. The de fi nition of “targeted case management” in Medicaid closely conforms to the broker model. In order to reimburse other case management models, states have to request a waiver or rename case management as a differ-ent service (e.g., community psychiatric support and treatment). In fee-for-service systems through Medicaid, billable case management activities are encouraged but others are not permitted. Examples often excluded are work with natural community resources, transportation to appoint-ments, and outreach.

Many case managers are increasingly working in isolation from other key professionals within community mental health centers. Cost cutting has in some cases eliminated frontline supervi-sors or has raised the number of case managers per supervisor to an extent that support is mini-mal. Training has also eroded for many case managers as a result of cost-saving measures.

Case managers today are also facing new and increasingly dif fi cult challenges without adequate resources to combat them. Basic social services, including housing subsidies and vocational services,


have eroded. Thus, homelessness, drug abuse, vic-timization, and health problems, such as HIV and hepatitis infections, have worsened. People with mental illness are increasingly shunted to the crimi-nal justice system, resulting in further stigma, abuse, and health insurance problems. Over-medication, polypharmacy, poor health behaviors, comorbid medical illnesses, lack of or inadequate medical care, and early mortality have become more salient and probably more prevalent.

Case management is expected to solve all of these problems and more. The expectations have risen from merely helping clients achieve stabil-ity and maintenance in the community to helping people achieve signi fi cant levels of recovery, which entails helping people achieve meaningful and important life goals. These increased demands have been accompanied by salaries that have been stagnant for years, less ongoing train-ing and supervision, and fewer contacts with psychiatrists and other professional colleagues. Is it any wonder that job satisfaction is low and that job tenure of case managers is so brief (about 18 months across the United States, Woltmann et al. 2008 ) ? The public mental health system is a shambles (New Freedom Commission 2003 ; NAMI 2006 ) , and case management as a profes-sion is parlous. Health care reform will undoubt-edly produce new forms of mental health care, which will, we hope, revitalize and strengthen case management.

The Basics of Effective Case Management Despite the challenges, case management can be a valuable and effective service when imple-mented properly. Several basic aspects of effec-tive case management are clear from the past decades of experience and research. As we look to strengthen case management in today’s envi-ronment, the following principles will need to be salient in health care reform and in emerging mental health structures. 1. Direct service delivery

This ingredient was present in each of the nonbroker model studies reviewed. In con-trast, common to each of the broker model studies is the reliance on referral, especially to mental health services (Curtis et al. 1992 ;

Franklin et al. 1987 ; Hornstra et al. 1993 ) . ACT and the Strengths Model prescribe that case managers should directly provide most of the services. Due to the fragmented nature of many mental health systems, this principle serves many practical purposes. Many people with psychiatric disabilities have dif fi culty navigating the large array of supports they may need. This becomes extremely dif fi cult in agencies where life domains are carved out among multiple specialists. For example, some agencies may have a housing specialist, employment specialist, education specialist, substance abuse specialist, life skills specialist, etc.

An important aspect of this principle is that case managers remain integrally involved with their clients’ goals, and negotiate their role relative to other providers’ involvement. For example, while we do not expect case manag-ers to prescribe or offer advice around psychi-atric medications, they could still have a role when a client has a goal to fi nd a medication that offers relief from distressing voices. Case manager roles might include: assisting the cli-ent to write speci fi c questions they had for their doctor, helping the client write speci fi c side effects they fi nd uncomfortable, and accessing information on nonmedical meth-ods of controlling voices (e.g., headphones, distracting techniques, etc.).

This principle does not preclude these types of specializations. In fact, having a Supported Employment specialist on the team is likely to increase employment outcomes for clients (Gold et al. 2006 ) . What this principle does suggest is that the case manager should have a central role even when a specialist is involved. For example, if a person is referred to Supported Employment because of an employment goal, the case manager would still be highly involved in the goal despite the referral. While the Supported Employment worker might assume high-skilled specialized roles (i.e., job devel-opment, vocational assessment, negotiating accommodations, etc.), the case manager could assist the client with other tasks around this goal that did not need this level of specialty


(e.g., developing a plan for getting to and from work, purchasing supplies or clothes needed for job, developing symptom self-management strategies, arranging child care, etc.).

2. Service delivery in the community An outreach style of service delivery is pre-scribed by both ACT and Strengths (Rapp 1993 ; Test 1992 ; Witheridge 1991 ) . There are multiple reasons for this principle. First, con-sumers highly value assistance with everyday problems (e.g., transportation, assistance in obtaining housing and living resources, assis-tance with medical care, etc.) (McGrew et al. 1996 ) and this has been found to be correlated with consumer satisfaction (Huxley and Warner 1992 ) . This is consistent with the idea that tan-gible forms of help are the most powerful in helping clients avoid rehospitalization (Bond et al. 1990 ) . These life tasks occur in the com-munity context where the help needs to be pro-vided: in apartments, restaurants, businesses, parks, and community agencies. If client self-determination was taken seriously, in vivo ser-vice delivery would be the norm since most clients prefer it (Rapp and Goscha 2006 ) .

Second, work in the community minimizes dropouts and enhances engagement. The evi-dence is overwhelming. ACT research consis-tently fi nds rates of retention for at least a year to exceed 80% (Bond et al. 1995 ) , which is considerably higher than the less than 50% for even 6 months found for traditional aftercare (Axelrod and Wetzler 1989 ; Bond et al. 1995 ) . ACT and Strengths experts both rated the importance of outreach and in vivo service delivery very highly (McGrew and Bond 1995 ; Marty et al. 2001 ) .

Third, work in the community assures that skills are being learned in the context in which they will be performed thereby avoiding prob-lems of generalization. There is little behavioral evidence that skills learned in one venue trans-fer to others (Bellack 2004 ; Gutride et al. 1973 ; Jaffe and Carlson 1976 ; Liberman et al. 1985 ) .

Fourth, work in the community allows more complete and accurate assessments. A person’s behavior is context-speci fi c. People often behave differently in mental health programs

than they do in community settings. The behavior of interest is that of the community not the behavior that occurs in contrived men-tal health programs surrounded by staff with their own culture and set of rules.

Fifth, and perhaps most importantly, the evidence strongly suggests that in vivo service leads to reductions in hospitalization. Bond ( 1991 ) commented that “one program using of fi ce visits because of a reluctance to make home visits had minimal success until it changed its treatment strategy” (p. 75). In a multisite study, Rosenheck et al. ( 1995 ) found that one site that provided intensive services, but did not provide them in community set-tings, actually increased both inpatient usage and costs by more than 50%.

3. Natural community resources Natural community resources refer to non-formal, nonsegregated resources provided by landlords, ministers, employers, teachers, com-munity colleges, neighbors. The primacy of this ingredient is consistent with notions of recovery that emphasize building a life apart from the mental health system (Ridgway 2001 ) . In fact, community integration has been viewed as a centerpiece of recovery where “people with disabilities live, work, play and lead their daily lives without distinction from and with the same opportunities as individuals without disabilities” (Bond et al. 2004 , p. 570).

ACT and the Strengths Model encourage case managers to do this rather than make referrals to specialized programs. In fact, the fi delity scales for both models have an item directed to this dimension (Rapp and Goscha 2006 ; Teague et al. 1998 ) . For example, work-ing with employers rather than using a shel-tered enclave or reaching out to landlords rather than referring to a mental health run housing program. The need for such an approach is obvious in rural areas that typi-cally lack formal services. The results in rural areas of this approach for both ACT and Strengths found signi fi cantly lower rates of hospitalization and high rates of goal achieve-ments in most life domains (Rapp and Wintersteen 1989 ; Santos et al. 1993 ) .


4. Small caseloads The expectations concerning the direct provi-sion of services, the outreach mode of service delivery, involvement with crises, highly indi-vidualized service, the breadth of life domains to be attended to, and the work with naturally occurring resources inevitably requires a rela-tively low consumer to staff ratio. Low ratios received virtuously unanimous agreement of ACT experts (McGrew and Bond 1995 ) . Davidson et al. ( 2006 ) views high caseload sizes as a concern in terms of the ability for mental health programs transformation to recovery ori-ented care. ACT programs recommended a 10:1 ratio (Test 1992 ; Witheridge 1991 ) . The Strengths Model suggests caseload sizes between 12:1 (Rapp and Wintersteen 1989 ) and 20:1 (Macias et al. 1994 ) . Mueser et al. ( 1998 ) recommends a case load size of 20–30:1. In two studies where the comparison to the ACT team had lower caseloads (Bond et al. 1991 ; Sands and Cnaan 1994 ) there were no signi fi cant dif-ferences in hospitalization outcomes.

Caseload sizes exceeding 20:1 are also con-traindicated for working with individuals with complex needs, including individuals who have substance abuse disorders, cognitive, and/or physical disabilities in addition to a mental illness. Traditional mental health programs have focused on symptoms reduction and stable living status as means of evaluating the effec-tiveness of their services. First person accounts of recovery reveal that people with psychiatric disabilities desire more than just having the ability to cope and maintain, but instead desire the achievement of goals that bring meaning, purpose, and identity to their lives. Case man-agement services that are reactive and/or crisis oriented are incongruent with this approach. High caseloads sizes limit case managers’ abil-ity to offer individualized services.

Both ACT and the Strengths Model suggest tailoring caseload size to the needs presented by people and the outcomes or bene fi ts sought by the intervention. For example, ACT recom-mends a 12:1 ratio when the caseload comprises only people with high hospital utilization or who are homeless. A ratio of 20:1 seems effective when it comprises people normally distributed

in terms of severity (Macias et al. 1994 ) and 30:1 if comprising people who are stable and more independent (Salyers et al. 1998 ) .

Three key points are salient here. First, frequency of contact rather than hours of con-tact makes a difference (McGrew et al. 1994 ; Rife et al. 1991 ) ; the use of telephone may be a helpful supplement, not a replacement. Second, frequency of contact and hospital out-comes will never be truly linear since those who are most in need will often receive the most contact but may also have higher rates of hospitalization (even if reduced compared to similar control groups). Third, the quality of the contact, not just frequency, is a mitigating factor. For example, small caseloads employ-ing ineffective methods or unskillful case managers would probably be ineffective. The study by Hornstra et al. ( 1993 ) is illustrative whereby a broker model intervention with small caseloads and signi fi cantly more case manager contact produced no outcome differ-ences compared to the control group.

5. Case managers and supervisors In the Unites States, case managers are mostly bachelors-level staff without education in one of the helping professions. Both ACT and the Strengths Model use teams of generalists with consultation by medical professionals and other experts as needed. Recommended experts would include employment specialists (Furlong et al. 2002 ; Gold et al. 2006 ; Bond 1998 ) and dual diagnosis experts (Drake et al. 2001 ) . ACT research has found that nurse par-ticipation on the team was correlated with positive outcomes (McGrew et al. 1994 ) .

There is considerable evidence that a wide range of people can be effective case managers including students (Modrcin et al. 1988 ; Rapp and Chamberlain 1985 ; Rapp and Wintersteen 1989 ) and consumers. One recent review concluded that studies of consumer-delivered services report equally positive outcomes as traditional services, particularly for practical outcomes such as employment, income, edu-cation, or living arrangements (Doughty and Tse 2011 ) which echoed an earlier review by Davidson et al. ( 2006 ) . The key seems to be the competency level of the staff person


delivering the service. The Strengths Model prescribes a list a behaviors and competencies that need to be performed in order to achieve high fi delity (Rapp and Goscha 2006 ) . Staffs are able to attain the needed skills to achieve pro fi ciency in the model through structured teaching methods employed by the supervisor.

The lack of professional training and rela-tively high turnover rates among case manag-ers is compensated, in part, by having high quality supervision from a seasoned profes-sional. In fact, the Strengths Model fi delity scale devotes one section to supervisory behaviors including group supervision of the team, fi eld mentoring and quality review of tools (Rapp and Goscha 2006 ) . Adopting a consumer outcome-based supervisory style has been recommended (Rapp and Goscha 2006 ) . In addition, access to in-service train-ing and technical assistance has been recom-mended (Bond et al. 1990 ) .

6. Choice The freedom to choose has been a stated value of community services for over a decade. In fact, self-determination and choice has been one of the six principles of the Strengths Model since its inception in the early 1980s. More recently, choice has become an integral part of the shared decision-making movement and its methods. The principle of choice is important considering research showing that people with psychiatric disabilities prefer active and col-laborative roles in terms of health care deci-sions (Hamann et al. 2006 ; Adams et al. 2007 ) . People with psychiatric disabilities who are able to actively participate in designing their own treatment plans are more likely to have an improved self-image, to be satis fi ed with the services they receive, and achieve their treat-ment goals (Chinman et al. 1999 ) . In a qualita-tive study on conditions that need to be present for client empowerment to occur through treat-ment planning, Linhorst et al. ( 2002 ) found that providing the client a range of treatment options was critical. In addition, it was noted that these options “must support the achieve-ment of clients’ self-selected goals” (p. 432).

There is an increasing body of research suggesting choice is also associated with

improved outcomes. In Supported Employment, interventions that base admis-sions merely on a person’s desire to work and which individualize job seeking to posi-tions conforming with people’s preferences produce higher rates of competitive employ-ment (Abrams et al. 1997 ; Becker et al. 1996 ; Gowdy et al. 2003 ; Mueser et al. 2001 ) .

In a review of supported housing research, Ridgway and Rapp ( 1997 ) found that when peo-ple had subsidies and options, most moved into independent living situations (Depp et al. 1986 ; Dixon et al. 1994 ; Newman et al. 1994 ) . In a ten-site pre–post national evaluation, increased sense of choice at baseline was found to be asso-ciated with improved satisfaction with housing and improved residential stability at follow-up (Livingston et al. 1991 ; Srebnick 1992 ) .

The importance of choice is also seen in motivational interviewing strategies used in integrated dual diagnosis treatment (Carey 1996 ; Drake et al. 2001 ; Miller and Rollnick 2002 ; Ziedonis and Trudeau 1997 ) . For exam-ple, it is the practitioner’s role to elicit “change-talk,” provide information, and clar-ify the client’s thinking, but all decision-mak-ing rests with the client. The importance of choice also resounds from the hundreds of fi rst person accounts of recovery.

7. Full-time access Each model argues that case managers should be accessible 24 hours a day, 7 days a week and most experimental conditions included this element. One of the reasons for team approaches is to spread this responsibility across team members. The ACT experts, however, reached relatively low levels of agreement on this ele-ment while the early Wisconsin efforts and some subsequent ACT programs adhere to this rigidly. Some ACT programs operate during business hours only. Even with great variation in this dimension across studies, positive out-comes have been reported regardless of the structure employed; therefore, this speci fi c component of service seems optional.

What is not optional is that people need access to crisis and emergency services, 24 hours a day, 7 days a week. The effectiveness of crisis services is enhanced by in-person or phone


access to staff who have familiarity and a rela-tionship with the person and who are committed to avoiding hospital care when possible (Carlson et al. 1998 ) . This would necessarily include the case manager, the team leader or supervisor, the team members, or in some small (probably rural) areas the crisis staffs themselves.

Psychiatric Epidemiology

Throughout the United States, case management services are inadequate (Wang et al. 2002 ) . In usual practice, only 2% of clients receive case management services approximating ACT (Lehman et al. 1998 ) . Budget constraints have led to the de facto adoption of brokered case management with high caseloads, in which cli-ents are referred to other programs and agencies for housing, employment, and other services. Individual caseloads averaging about 30 clients are common (Boyer and Bond 1999 ; Ellison et al. 1995 ) , but this average camou fl ages much larger caseloads, ranging up to 300:1 (Ellison et al. 1995 ) . As noted above, brokered case manage-ment with high caseloads is not only ineffective but contributes to deterioration in client function-ing (Rapp and Goscha 2004 ) .

It has been long been recognized that case management services should be titrated to the level of client need (Giesler and Hodge 1998 ) . At one extreme would be people who are acutely psychotic, dangerous to themselves and others, and/or are not lucid. Their lives are often in “sur-vival mode” just trying to eke out an existence day by day. A middle group is in the process of recovering their lives and have goals (whether modest or not) where the disability impedes prog-ress. The other end of the continuum contains people who are stable, living their lives in ways that bring them satisfaction despite the disability. In light of health care changes in the United States, it remains an open question how to allocate resources to staff such tiered services, and whether to incorporate step-down mechanisms and hybrid models established to respond to fl uctuating needs (Salyers et al. 1998 ; van Veldhuizen 2007 ) .

A fundamental ACT principle is targeting a circumscribed population: adults with SMI who

do not bene fi t from usual care (e.g., clients with a history of frequent or long-term hospitalizations, co-occurring substance use disorders, homeless-ness, involvement with the legal system, or other indicators of not bene fi ting from less intensive services). According to this view, ACT is appro-priate for people at the most severe disability end of the continuum, and not appropriate for the large majority of clients with SMI in the public mental health system, in part because of resource issues. Speci fi cally, ACT is not cost-effective if provided to clients with SMI without regard to service need (Burns et al. 2007 ; Latimer 2001 ) . Two basic questions, then, are the following: What proportion of the SMI population should receive ACT? What kind of case management services should be provided to clients not receiv-ing ACT?

Two recent studies have sought to address the question of needed capacity for ICM/ACT ser-vices in a given geographic area. Using tradi-tional ACT hospitalization criteria, their estimates ranged from 50% (Cuddeback et al. 2006 ) to 80% (van Veldhuizen 2007 ) of all clients in the service area—which would be prohibitive from a resource perspective. These estimates are based on a generally outdated premise that ACT teams are designed primarily to serve frequently users of psychiatric hospitals, which was the primary mis-sion for ACT in the 1980s (Bond et al. 1995 ; Mowbray et al. 1997 ) . Because of deinstitution-alization, far fewer clients are hospitalized at any time and inpatient stays are now much shorter in the United States (Lamb and Bachrach 2001 ) . Thus, the original mission for ACT has been largely eclipsed, except in countries such as Japan, where deinstitutionalization has not yet occurred (Ito et al. 2009 ) .

Another complicating factor in ACT eligibil-ity estimation is that ACT services do not exist in a vacuum. Inadequate basic mental health ser-vices (e.g., housing, other community support services, crisis services) may lead to clients’ dete-rioration and increased need for ACT. Since people often stay on ACT teams for prolonged periods of time, ACT services become unavail-able for new clients. So this begs the question: what should case management services look like for the remainder of the SMI population?


The Strengths Model was primarily designed for those individuals who still experience signi fi cant barriers and challenges to goal achievement because of the disability, but do not require the intensity of services like ACT. While Strengths Model philosophies, tools, and meth-ods can be used within ICM services, the model is most applicable to the middle group mentioned above. Using the data from the two studies above (Cuddeback et al. 2006 ; van Veldhuizen 2007 ) , 50–80% of all people in a service area could bene fi t from Strengths Model services. The cli-ents served by the Strengths Model in the research conform to the parameters of this middle group.

Prevention

The case management services described in this chapter aim at preventing negative outcomes such as psychiatric crises, unnecessary psychiatric hospitalizations, and homelessness. Case man-agement services are most effective when they are proactive, ensuring that clients have basic resources and access to needed psychiatric ser-vices and that they have developed relapse pre-vention strategies, all of which help prevent negative outcomes. The extent to which different case management approaches have been suc-cessful in preventing negative events has been discussed above.

One other important area of prevention, not discussed in this chapter, is prevention of disabil-ity through early intervention with clients experi-encing their fi rst episode of psychosis (Killackey et al. 2006 ) . In this population, duration of untreated psychosis is negatively associated with outcome (Marshall et al. 2005 ) . One goal of early intervention programs for this population is to bypass the cycle of decline that leads clients to applying for Social Security disability bene fi ts accompanied by the formation of an identity as a disabled person (Estroff et al. 1997 ) . The National Institute of Mental Health is supporting large-scale research on identifying the critical ingredi-ents of a package of services to address the needs of this population (Hsiao 2008 ) . The service model will likely include strengths-based case management and assertive outreach, in addition

to supported employment and supported education and other interventions.

Advocacy

The hallmark of the effective case management approaches is advocating for clients with regard to their personal goals. The advocacy often takes the form of facilitating acquisition of community resources—to competitive jobs, community housing, recreational services, and the like. Given the importance of using naturally occurring resources, advocacy targets a wide range of people and organizations that control resources needed or desired by clients. There are four dimensions of resource advocacy: availability, accessibility, accommodation, and adequacy. Availability refers to the presence of a needed resource. Accessibility relates to the ability of the client to make use of the available resources which could include consideration of transporta-tion, entrance requirements or prerequisites for use, cost, etc. Accommodation addresses possible adaptations that may be needed for the client to make use of the resource. In employment, exam-ples could include hours, frequency of breaks, or the actual structuring of work duties. Lastly, ade-quacy refers to how well the resource meets the needs of each particular person. Is it contributing to personal ful fi llment and satisfaction or to the achievement of their personal goals?

While negative strategies (e.g. threatening to sue, involving the media) are occasionally neces-sary, most successful advocacy efforts are rela-tionship based and assume that most people are open to helping people with psychiatric disabili-ties (Rapp and Goscha 2006 ) . For example, advo-cating for employment for a client is best served by a job development approach that seeks to build a relationship with the employer (Carlson et al. 2008 ; Bissonnette 1994 ) .

Conclusions

Case management has been a central feature of community mental health care for people with serious mental illnesses for nearly 50 years.


An accumulated evidence base strongly supports the effectiveness of speci fi c models of case man-agement, especially ACT and the Strengths Model, and of several basic elements of case management, such as direct delivery of services in the community.

Nonetheless, challenges to evidence-based case management are legion: social and economic changes in society, criminalization of people with mental illness, erosion of support services, pres-sures for cost control, high prevalence of medical problems, and health care reform. As new forms of community mental health care emerge, case management will inevitably be affected. The les-sons of the past 50 years should critically inform the reconstruction process.

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Handbook of Community Psychiatry || Case Management and Assertive Community Treatment