We describe different models of community care for persons with severe mental illness and review the research literature on case management, including the results of 75 studies. Most research has been conducted on the assertive community treatment (ACT) or intensive case management (ICM) models. Controlled research on ACT and ICM indicates that these models reduce time in the hospital and improve housing stability, especially among patients who are high service users. ACT and ICM appear to have moderate effects on improving symptomatology and quality of life. Most studies suggest little effect of ACT and ICM on social functioning, arrests and time spent in jail, or vocational functioning. Studies on reducing or withdrawing ACT or ICM services suggest some deterioration in gains. Research on other models of community care is inconclusive. We discuss the implications of the findings in terms of the need for specialization of ACT or ICM teams to address social and vocational functioning and substance abuse. We suggest directions for future research on models of community care, including evaluating implementation fidelity, exploring patient predictors of improvement, and evaluating the role of the helping alliance in mediating outcome.

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Models of community care for severe mental illness : A review of research on case management

Background. The concept of ‘continuity of care’ has changed over time and seems to be entangled with other care concepts, for example coordination and integration of care. These concepts may overlap, and differences between them often remain unclear. Objective. In order to clarify the confusion of tongues and to identify core values of these patientcentred concepts, we provide a historical overview of continuity of care and four related concepts: coordination of care, integration of care, patient-centred care and case management. Methods. We identified and reviewed articles including a definition of one of these concepts by performing an extensive literature search in PubMed. In addition, we checked the definition of these concepts in the Oxford English Dictionary. Results. Definitions of continuity, coordination, integration, patient-centred care and case management vary over time. These concepts show both great entanglement and also demonstrate differences. Three major common themes could be identified within these concepts: personal relationship between patient and care provider, communication between providers and cooperation between providers. Most definitions of the concepts are formulated from the patient’s perspective. Conclusions. The identified themes appear to be core elements of care to patients. Thus, it may be valuable to develop an instrument to measure these three common themes universally. In the patient-centred medical home, such an instrument might turn out to be an important quality measure, which will enable researchers and policy makers to compare care settings and practices and to evaluate new care interventions from the patient perspective.

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How unique is continuity of care? A review of continuity and related concepts

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Clinical services research.

We present and test a model for measuring the implementation of Community Support Programs (CSPs) for persons with severe mental illnesses. The model is intended to facilitate the description and replication of these programs and the future study of their critical ingredients. The model defines important implementation variables in seven areas of program functioning; we then suggest instruments to measure each of these variables. Results of a study examining the application of the model and measures forthree conceptually distinct CSPs illustrate the utility of the model and measures for implementation analysis of CSPs. Importantly, findings revealed thata priori hypotheses about how the programs were expected to differ on the implementation variables were largely supported.

A model for measuring the implementation of community support programs: results from three sites.

This paper defines case management, traces the historical development of the concept, and sets out the principles and core tasks of this approach to coordinated care for the long-term mentally ill. It is argued that case management is a term which is applied to a wide range of practices which are more specifically characterized with references to twelve axes: individual or team orientation, direct care or brokerage, the intensity of the interventions, the degree of budgetary control, health or social service as the lead agency, the status and specialization of the case manager, the staff to patient ratio, the degree of patient participation, the point of contact, the level of intervention, and the target population.

The concept of case management for long-term mental illness

A method is presented for measuring the activities of case management in the care of the severely mentally disabled in catchmented public community mental health systems. Two variants of the method were compared, interviewing case managers and record abstracting. The methods were tested in two community mental health center (CMHC) sites, and appear to yield comparable results. The record abstract method seems workable for retrospective examination of case management in a CMHC system, and for the comparison of case management in different systems.

Measuring case management activity.

"Restrictiveness" is neither a narrow legal concept nor a clinical concept that encompasses all aspects of a patient and his treatment; it refers to several features of treatment that can infringe on individual freedoms. As part of a study to develop a reliable method to measure restrictiveness, 31 mental health professionals were asked to rate the restrictiveness of six dimensions of treatment, such as legal status, and 33 treatment alternatives. Interrater reliability was high for both the importance of dimensions (alpha = .92) and the restrictiveness of alternatives within dimensions (alpha = .99). The treatment dimension judged most important in assessing restrictiveness was "limitations of physical freedom." The scale resulting from these judgments offers a plausible measurement of the restrictiveness of treatment configurations for use in evaluation research. The authors caution that restrictiveness is not in itself a comprehensive index of the quality of psychiatric care.

Measuring Restrictiveness of Psychiatric Care

Restrictiveness of care was assessed among 286 severely mentally disabled individuals known to an urban community mental health center. By examining dinical records, the authors rated each subject for each month during a period of up to 85 months on four dimensions of restrictiveness: physical freedom, time constraints, legal status, and conservatorship. The maximum restrictiveness experienced by most of the subjects was high, reflecting periodic involuntary hospitalization. The average restrictiveness they experienced, however, was well below the level represented by state hospital care. Thus the authors suggest that the average restrictiveness experienced by this population has been reduced since the initiation of deinstitutionalization.

Restrictiveness of Care Among the Severely Mentally Disabled

The present study surveyed federally-funded emergency psychiatric programs in 33 California community mental health centers (CMHCs). Four aspects of service organization were examined: (1) the availability of various response styles (telephone service, walk-in service, follow-up home visits, mobile initial response); (2) the types of staff providing the service; (3) the location of the programs, and (4) the organizational setting of the CMHCs (consortium or single agency centers). From these characteristics of service organization two contrasting types of emergency psychiatric programs were derived—the “emergency room” and “mobile response” models. The relationship between these two models of service delivery and catchment area demographic characteristics was examined and no remerkable trends emerged. The implications of developing a typology of emergency psychiatric programs are discussed with respect to a scheme for evaluating the relative effectiveness of services and for planning future programs.

Jessica Gaynor

Papers

Measuring case management activity.

Measuring Restrictiveness of Psychiatric Care

Restrictiveness of Care Among the Severely Mentally Disabled

"Emergency room" and "mobile response" models of emergency psychiatric services.