Case Management: Scientist vs. Health Professional Issues

1. Case Management: Scientist vs. Health Professional Issues

2. Case Management: Frames of Reference • When considering any major issue ( particularly in the field of health and human services), frameworks are most influential in identifying issues of importance, in evaluating information etc.. • Consider the problem of unemployment: • Sociological framework; • Psychological framework.

3. Two Frameworks for Evaluating Case Management • That of the scientist • That of the health professional (or service manager)

4. Case Management: Scientific Concerns • To the scientist approaching case management, there are some “obvious” initial questions: • Is CM effective? • Are some forms of CM more effective than others?

5. Is Case Management Effective? • Comment: • It’s a broad question similar to other famous broad questions in health and human service delivery. • c.f.: Is psychotherapy (“talking” therapy) effective? • c.f.: Does punishment work?

6. Is Case Management effective? (continued) • Consider the famous Eysenck (1952) paper • See the stream of follow-up papers it stimulated for the next 40 years (e.g., Crits-Cristoph’s 1992 meta analysis of brief psychotherapy)

7. Eysenck’s (1952) conclusions • On the basis of the evidence he compiled, Eysenck concluded that (among neurotic clients) the rate of improvement was no greater than the rate of spontaneous remission. • Whether neurotic clients received psychotherapy or not, two-thirds reported substantial improvement within a period of two years.

8. Conclusions from the debate over Eysenck’s (1952) conclusions • Need to conduct more systematic reviews of the evidence, using mostly controlled studies involving research designs of “high methodological quality”.

9. More conclusions from the Eysenck (1952) debate • Studies of the effect of “service X” or “treatment X” often overlook an examination of the effect on service/treatment outcome of: • Client factors (e.g., personal control orientation) • Therapist factors (e.g., skill in basic counselling and communication) • Contextual environmental factors (e.g., social support; system barriers and facilitators)

10. Learning fromthe debate over Eysenck’s (1952) conclusions • Need to be more precise in our forming of the key research question • Is treatment X (when delivered reliably), effective for (what group of) clients presenting with what specific problem?

11. Contemporary position re evaluation of treatment effectiveness • The evidence-based medicine movement (Cochrane library) • Limitations of the Cochrane approach

12. Case Management: Health Professional Concerns(or service manager concerns) • To the health professional (or managers of those involved in service delivery) there are a large set of priority questions to do with the practical problem of making “case-management” function as well as it can. • Issues re the “satisfaction” of individual workers vs their “satisfactoriness”

13. Case Management: Health Professional Concerns(or service manager concerns) • How does one organize the work-place so that the case manager is satisfied and satisfactory? • These are the traditional concerns of the organisational psychologist.

14. Health Professional Concerns(or service manager concerns) • If case-manager satisfaction and satisfactoriness is high, to what extent are clients’ significant others also “satisfied” • Employers (for occupational rehabilitation) • Family members (for community based psychiatric services) • Health professionals in other “systems” (e.g., GPs, medical specialists, private practitioners handling patients/clients on a fee-for-service basis).

15. Case Management: Health Professional Concerns(or service manager concerns) • The questions about the case manager’s satisfaction and satisfactoriness call for knowledge from organisational psychology and/or human resource management

16. Case Management: Frames of Reference (reprise) • If I look at case management as a scientist I am going to focus on a certain set of questions and review a certain literature. • In preparation for this, I spent some (considerable) time working from this traditional scientific framework.

17. Case Management: Frames of Reference (reprise) • If I look at case-management as an organisational psychologist, or someone interested in the effective use of human resources within human service organisations, I will review a very different (and much smaller) literature.

18. Case Management: Frames of Reference (reprise) • Before I report my overview summarising what we know about case management as a mode of service delivery, let me put before you a practical question.

19. Case Management: Frames of Reference (reprise) • If the evidence from traditional research into case management is equivocal (as one could predict), then should not more research be undertaken in case management from an organisational psychology perspective?

20. Case Management: Scientific Issues • Fundamental question to be answered (before questions about effectiveness can be addressed ): • What is Case Management?

21. What is Case Management? • “Currently there appear to be many conceptions, people often taking one particular case management model as the only true version” (Pilling, 1992) • “…nobody quite knows what case management is” (Rothman, 1991)

22. What is Case Management? • The term ‘case management’ evokes a sense of understanding that is more elusive than is generally acknowledged…what is, or is not, identified as case management is often determined by the commentator’s own position in the field (Gursansky et al., 2003)

23. What is Case Management? • “There are several models of case management within contemporary mental health services” (Rosen and Teeson, 2001) • Thornicroft (1991) used 12 axes to describe variants of case management in practice. Variants ranged from intensive action models to passive-response, more sedentary brokerage styles of case management.

24. Conclusions from the examination of attempts at defining case management • There are various models and forms of “case management” • “Case management is not a single service approach in the way that use of Drug X is one treatment for Condition Y.

25. Case management: results from scientific investigation of its “effectiveness” • I will not attempt to produce the results of a professional academic review of the evidence for case management effectiveness • I will draw your attention to a few facts and trends in the literature

26. Case management: some findings from searching relevant scientific data-bases • Using CINAHL, if you enter “case management” and restrict the search to the last five years and to papers with full text available, and then refine by use of the modifier “Evaluation”, N = 99 identified items.

27. Case Management Evaluations: CINAHL • Some trends in the populations studied, with most represented being: • Elderly • Pediatric (chronic or hospitalised patients) • Serious mental illness • CM within the hospital

28. Case Management Evaluations: CINAHL • Less frequently represented than I had expected: • ABI • Workers compensation • SCI • Unusual: • Public health practice CM was comparable to the above groups in frequency

29. Case Management Evaluations: CINAHL • Results from “controlled” studies of CM vs. regular service (N = 6 Studies) • NSD = 3 studies • Significant difference (negative) = 2 studies • Significant difference (positive) = 1 study.

30. Case Management: Cochrane Library • Step 1: Search for items dealing with “Case Management” • (N = 624) • Results: • Systematic reviews (n = 54) • All other items (n = 570)

31. Case Management Systematic Reviews from the Cochrane Library (N = 54) • Step 2: Of the 54 identified systematic reviews • 41 complete reviews • 13 protocols for the reviews

32. Case Management Complete Reviews from Cochrane Library • Step 3: Of the 41 complete reviews, • review of case management = 1; • other reviews which mentioned case management inter alia = 40.

33. Focus of “other reviews”(n = 40) • Examples of non-CM reviews • CBT for schizophrenia • Day hospital vs. outpatient care for psychiatric disorders • Interventions for smoking cessation in hospitalised patients

34. Conclusions of the single review of CM effectiveness within the Cochrane Library • CM ensures that more people remain in contact with psychiatric services. • CM approximately doubled the numbers admitted to psychiatric hospital (OR = 1.84, 99% CI = 1.33-2.57).

35. Conclusions from Marshall et al., (1997) • “…Case management is an intervention of questionable value, to the extent that it is doubtful whether it should be offered by community psychiatric services…”

36. Conclusions from Marshall et al., (1997) • “It is hard to see how policy makers who subscribe to an evidence-based approach can justify retaining case management as “the cornerstone” of community mental health”.

37. Results from the Cochrane Library Abstracts (N =31) • Only 5 relevant • Holloway et al. (1995) (Psychiatric services) • Fergusen & Weinberger (1998) (Various medical) • Norris et al. (2002) (Diabetes mellitus) • Ziguras & Stuart (2000) (Severe mental disorders • Mueser et al. (1998) (Severe mental illness)

38. Findings from review abstracts ( n = 5) • Holloway et al (1995) • From 21 studies, decrease in hospitalisation in 11, no difference in 7 and increase in the remainder. • Fergusen & Weinberger (1998) • From 7 studies of hospital utilisation, 2 reported reductions and the remainder found no change or increased utilisation.

39. Findings from review abstracts ( n = 5) • Norris et al. (2002) • Case management was effective for glycated haemoglobin control (18 of 19 studies) • Ziguras & Stuart (2000) • Compared with usual treatment, CM was associated with the following • Lower drop out rates ( r = .33) • Greater family satisfaction with care (r = .42) • However, patients on case management were admitted to hospital more frequently.

40. Findings from review abstracts ( n = 5) • Mueser et al., (1998) • Of 23 studies that examined hospital time, 14 (61%) reported significant reductions compared with the control group.

41. Conclusions from review abstracts

42. Conclusions from Register of Controlled Trials (N = 399)

43. Overall conclusions from the reviews of literature in CINHAL and Cochrane • CM is associated with quite varied outcomes: Sometimes superior to standard treatment; often no difference; sometimes inferior.

44. Questions raised bythe literature identified in CINHAL and Cochrane • Is there any order to the patterns of • Improvement vs. no effect? • Improvement vs. decrement?

45. Too early to draw conclusions, but,… based on results with “talking therapies” • Four factors exerting influence on patient change • 1. Extra therapeutic 40% of the “effect” • 2. Relationship 30% • 3. Placebo 15% • 4. Structure, model or technique 15% • (Norton, 1997)

46. Logical conclusions from research into CM effectiveness • We need to be more precise in the specification of our research questions • Thus, rather than seek to answer the question “does CM work?”, we should state questions in line with the approach of Chambless & Hollon (1998)

47. Questions to be answered, according to Chambless and Hollon (1998) • A. Is a clearly specified intervention efficacious with a particular population? • B. Is the intervention effective in non-laboratory or “natural” settings? • C. What is the cost-benefit of intervention?

48. Case management: Health professional issues (and/or service manager issues) • If we hold aside the scientific questions that need to be answered by researchers, we can approach case management from our second perspective: the concerns of the health professional occupying the CM role, and/or the concerns of a manager whose service has adopted “case management”.

49. To answer the practical questions to do with performance of case managers (i.e., how satisfying is the work of a CM? How satisfactorily do CMs perform?) – one needs to be informed by models of effective work performance such as the organisational systems approach of Katz and Kahn (1980), and the OB framework of Porter & Miles.

50. Applying the organisational model of Katz & Kahn (1980) to the job of the case manager • Premise 1: An organisation is a system of social roles • Question 1: How are roles of CMs to be understood?