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On-Line Journal
Article
A Model
for Team Case Management
Robert
B. LeLieuvre, University of Great Falls, April 20, 1999
Abstract
Although innovations in treating individuals with severely and persistently disabling mental illnesses predate managed care, the increasing number of mental health managed care programs in the private and the public sector places a premium on conceptualizing, testing, and implementing newer ideas and models of services. That case management is an important element in these newer services is easily seen by reviewing extant service delivery systems across the country. This paper presents one such proposed model.
Although innovations in treating individuals with severely and persistently disabling mental illnesses predate managed care, the increasing number of mental health managed care programs in the private and in the public sectors places a premium on conceptualizing, testing, and implementing newer ideas and models of services. One component of such services is case management. That case management plays a central role in the mental health service array is clear when one reviews extant service delivery systems across the country. The model proposed in this manuscript borrows heavily from the innovative works of Fairweather and colleagues (1969, 1980, 1993, 1994), Mosher and Burti (1989, 1994), Sarason (1972) and Seligman and colleagues (1993, 1995). It also draws on theory and research from community and social psychology, as well as contemporary thinking about behavior settings.
Drawing from these somewhat divergent perspectives, a case management team is multidisciplinary, consisting of a licensed mental health professional, two dedicated case managers, and one person with experience in supported employment and vocational rehabilitation and training. The four-person team has full clinical responsibility for a case load of between 25 and 50 individuals, determining and providing all activities, programming, and interventions, except hospitalization. In ongoing collaboration with the people it serves and a variety of community agencies, the team provides case planning, clinical treatment, psychosocial educational, crisis stabilization, day treatment, role recovery readiness assessment, pre-vocational planning, and community integration services. The proposed model's overarching philosophy is to restore and to increase, to the extent possible, the social statuses of demoralized, troubled and troublesome, dependent "veterans" of the mental health system. Three values or goals derive from this philosophy: (1) transferring and preserving personal power over one's life to the client; (2) transferring and preserving decision making responsibility for living to clients through three stages - professional responsibility and control (the present state) through shared responsibility and control to client authority; (3) teaching, training, coaching, and supporting clients in making appropriate and adequate choices in basic life areas - housing, living skills, relationships, social/leisure activities, and employment. As the team case management process unfolds, clients make decisions in those areas where they demonstrate proficiency. Through case management activities, they learn skills in those areas where they have not demonstrated proficiency. The ultimate goal is to provide the necessary array of activities so that the clients develop the ability to make those decisions required in everyday living and for any emergency that might arise.
In addition to various elements of the individualized service plans, developed and monitored weekly, clients are expected to participate in two special groups. The first is the Life Achievement Group (Fairweather & Fergus, 1993), a structured process focused on collaboratively and supportively developing plans for the basic life areas above. The second is a cognitive therapy group derived from Seligman's (1993, 1995) models of changing learned helplessness and learned pessimism. Each group meets for 75 to 90 minutes every week, and is facilitated by the licensed mental health professional and one rotating member of the case management team and/or a client (see below for a description of which clients might serve in this capacity). Depending on the total number of clients on the team's caseload, there may be more than one section of each group.
The model is data-driven and outcomes-driven. Base rate data are collected for the outcomes (see below) for a three-year period preceding a client's entry into the case management process, and each client completes the Attribution Style Questionnaire (Seligman, 1995) at time of entry. These data serve as the basic comparison data-sets for each client for as long as the client is involved. Four general positive outcomes (i.e., target behaviors expected to increase) and four negative outcomes (i.e., target behaviors expected to decrease) are proposed. The former include: (1) independent living - days per month and/or quarter; (2) social contacts - people, groups, or activities in the community per month and/or quarter; (3) training or education - enrollment in and completion of lectures, workshops, classes, or programs in any given year; (4) work or employment - part-time or full-time volunteer, supported, or competitive work days per month and/or quarter. The latter include: (1) emergent crises - number of after-hour emergency phone contacts and/or emergency room presentations per month and/or per quarter; (2) number of hospital admissions and days inpatient per month and/or quarter; (3) number of contacts with the criminal justice system or other agencies of social control and number of days incarcerated per year; (4) number of days spent exclusively at the community support program, the day treatment facility, and/or a drop-in center per month and/or quarter.
A client's scores on the ASQ is classified into quartiles, with the highest quartile indicating that the client has an optimistic explanatory style. The remaining three quartiles indicate, in descending order, that the client has an increasingly pessimistic explanatory style. Clients in the highest or most optimistic quartile can, if they so choose, serve as co-facilitators of either of the proposed groups, and as a control group for the cognitive therapy group in which clients in the other three quartiles participate.
This model of team case management is essentially conceptualized as an innovative and ongoing field experiment in natural settings. As such, data are continually collected and continually compared to baseline data on all clients. It is designed to work either within existing mental health service agencies or independently through consultation agreements and/or memoranda of understanding with available, clinical and psychiatric practices or hospitals (i.e. HMO, PPO, etc). The fee or rate structure - fee-for-service, case rates, or capitation - is in large part dependent on the location of the program (i.e. urban, rural, or frontier), the credentials of the professionals, the nature of the funding source, and the particular type of MCO responsible for the financial arrangements.
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