CHAPTER 7
PSYCHIATRIC CASE MANAGEMENT
E. J. Ernst
Jennifer Spies
CHAPTER CONTENTS
Historical Evolution of Psychiatric Case Management
Interpersonal Perspectives for Case Management
Measurement of Quality in Case Management
EXPECTED LEARNING OUTCOMES
After completing this chapter, the student will be able to:
1. Define case management
2. Trace the historical evolution of psychiatric case management
3. Identify the prominent case management models
4. Describe the specific role case management has in mental health care
5. Discuss the functions and activities involved in case management
6. Identify the goals and principles associated with case management
7. List the skills needed to function as a psychiatric-mental health nurse (PMHN) case manager
8. Explain the roles assumed by a PMHN case manager
9. Correlate how the interpersonal process relates to case management
KEY TERMS
Broker case management model
Case management
Clinical case management
Colorado model
Inpatient psychiatric case management model
Managed care agent
Managed care organization
Case management has evolved over the decades to meet the needs of patients in a variety of settings. Psychiatric nursing case management has evolved through the blending and adaptation of the definitions of case management. Case management has a rich history that is not exclusive to the psychiatric-mental health nurse (PMHN). Case management includes other disciplines such as social workers, psychiatrists, PMHN practitioners, occupational therapists, and nurses making up the multidisciplinary team. The PMHN has played an important role for patients with wide-ranging psychiatric diagnoses spanning multiple settings. The therapeutic interpersonal relationship is the foundation of psychiatric-mental health nursing. It is important for the PMHN case manager to integrate interpersonal relationships throughout the case management process while building on the strength of the existing relationship (Happell, 2012).
This chapter addresses the topic of case management and the role of the case manager in psychiatric-mental health nursing practice. This chapter provides a definition for case management and traces the historical evolution of psychiatric case management. It reviews the key psychiatric case management models and the goals, principles, and skills involved in the case management process. Case management is associated with the reduction of symptoms as well as a decrease in hospitalization. The chapter integrates the interpersonal process with case management, describing the roles of the PMHN case manager. The chapter concludes with a description of how case management relates to quality of care.
DEFINITION OF CASE MANAGEMENT
CASE MANAGEMENT refers to an outcome-oriented process that coordinates care and advocates for patients and patient populations across the health care continuum. Although other definitions of case management also exist, Box 7-1 presents two definitions by key professional organizations. The underlying theme for all the definitions is collaborative action for outcome achievement. The results are reduced cost, decreased use of resources, and improved quality of care.
Case management spans health care to include multidisciplinary health professionals, insurance companies, and MANAGED CARE ORGANIZATIONS. Managed care is a system of health care delivery and financing that is designed to control health care costs. Health care clinicians may approach case management as a method to provide continuity of care for patients. Case management is not managed care. However, insurance companies and managed care organizations may view case management as an opportunity to regulate the services provided to individuals, thereby controlling costs. Thus, conflict in case management may occur because of the ideological difference in the perception of the role of case management (Belcher, 1993).
The American Nurses Association (ANA) approved a definition of case management, which was later adopted by the American Nurses Credentialing Center (ANCC). The ANCC is the certifying body in nursing that provides certification for many nursing specialties, including the practice of case management in nursing. The ANA defines nursing case management as:
a dynamic and systematic collaborative approach to providing and coordinating health care services to a defined population. It is a participative process to identify and facilitate options and services for meeting individuals’ health needs, while decreasing fragmentation and duplication of care, and enhancing quality, cost-effective clinical outcomes. The framework for nursing case management includes five components: assessment, planning, implementation, evaluation, and interaction. (ANCC, 2000, p. 27)
BOX 7-1: DEFINITIONS OF CASE MANAGEMENT
“A collaborative process of assessment, planning, facilitation, care coordination, evaluation, and advocacy for options and services to meet an individual’s health needs through communication and available resources to promote quality, cost-effective outcomes.”
“An intervention in which health care is integrated, coordinated, and advocated for individuals, families, and groups who require services. The aim of case management is to decrease fragmentation and ensure access to appropriate, individualized, and cost-effective care. As a case manager, the nurse has the authority and accountability required to negotiate with multiple clinicians and obtain diverse services.”
—The American Nurses Association (ANA), American Psychiatric Nurses Association (APNA), and International Society of Psychiatric-Mental Health Nurses (ISPN), 2007, all have adopted these definitions.
From Standards of Practice for Case Management (2011).
The ANA, in conjunction with the American Psychiatric Nurses Association (APNA) and the International Society of Psychiatric-Mental Health Nurses (ISPN), defined case management as:
a clinical component of the psychiatric-mental health nurse’s role in both inpatient and outpatient settings. Nurses who are functioning in the case manager role support the patient’s highest level of functioning through interventions that are designed to enhance self-sufficiency and progress toward optimal health. These interventions may include risk assessment, supportive counseling, problem solving, teaching, medication and health status monitoring, comprehensive care planning, and linkage to, and identification and coordination of, various other health and human services. (ANA, APNA, & ISPN, 2007, p. 90)
This definition became part of the Psychiatric-Mental Health Nursing: Scope and Standards of Practice published in 2007.
Case management refers to an outcomeoriented process that coordinates care and advocates for patients and patient populations across the health care continuum. Although not exclusive to psychiatric- mental health nursing, it is an important component of psychiatric- mental health nursing.
HISTORICAL EVOLUTION OF PSYCHIATRIC CASE MANAGEMENT
Case management is a practice strategy that has been in existence for more than half a century. Early on, case management occurred primarily in public health settings, eventually expanding into the insurance industry. In the 1980s, the establishment of diagnosis-related groups (DRGs) created a prospective payment system based on categories of patient diagnoses. Institutions were being paid a predetermined amount based on the diagnosis rather than being paid for the actual cost of care. DRGs fueled further growth as case management began being implemented in acute care facilities.
Psychiatric-mental health case management and the role of the PMHN case manager have evolved significantly over the past decades. Two events in the mid-20th century spurred the use of case management in psychiatric-mental health nursing. The initial event involved the return of World War II veterans experiencing psychiatric conditions. The second event was the deinstitutionalization of chronic mentally ill individuals.
The return of World War II service members with psychiatric conditions changed the way mental health services were offered by the Department of Veterans Affairs Medical Administration (VAMC). The concept of caring for patients across a continuum evolved after World War II to describe the extended community services needed for mental health patients. The VAMC developed a model of case management that addressed not only the psychiatric needs of the veterans but also their health and social service needs (Kersbergen, 1996).
The deinstitutionalization of psychiatric inpatients in the 1950s and 1960s resulted from the advancements of medications specifically targeting the chronically mentally ill individuals’ most troubling symptoms. Pharmacological advancements prompted the movement of individuals from large, locked psychiatric inpatient institutions to community settings. Case management services expanded and were refined in the 1970s to include community mental health centers. These centers offered supportive community-based services to chronic mentally ill persons living in community settings after having been institutionalized for many years or, in some cases, decades (Herrick & Bartlett, 2004). The case manager in a community mental health setting provided a wide range of services such as helping the patient with housing needs, linking them with workforce re-entry services, ensuring they had adequate food resources, assisting them with transportation needs, assessing medication compliance, and assessing daily functioning. Case management became an important means to ensure the delivery and coordination of community services for these individuals with chronic mental health conditions (Lee, Mackenzie, Dudley-Brown, & Chin, 1998; Yamashita, Forchuk, & Mound, 2005). The goal of case management programs in community mental health settings was to keep the mentally ill out of locked, inpatient hospitals and in the least restrictive community setting.
Case management received U.S. government support in the 1970s. A major stipulation of this support was that community mental health settings assign an individual to mentally ill patients to coordinate their care (Herrick & Bartlett, 2004). Case managers were to assist patients in setting and achieving realistic goals and in utilizing resources appropriately so that patients could live, learn, and work in the social systems of their choice.
Returning World War II veterans experiencing psychiatric conditions and the deinstitutionalization of chronic mentally ill patients are two key events that prompted the evolution of psychiatric-mental health case management.
Case Management Models
As case management evolved in the general health care arena and psychiatric-mental health nursing, the models for delivery of case management also have grown. These models developed in response to the diverse needs of a wide range of mentally ill patients. Currently, multiple case management models exist, with the PMHN providing services to patients in inpatient and outpatient settings. The PMHN may assume the role of primary case manager or function as part of a case management team in collaboration with other health professionals. The spectrum of case management services ranges from the least intensive services, that of the case management service initiator, to the most intensive case management services, that of the clinical case manager. The level of service ideally is based on the patient’s acuity level and psychiatric stability. Patients at high risk for homelessness, substance abuse, incarceration, decompensation, and/or rehospitalization require a more intensive model of clinical case management (Malone, Workneh, Butchart, & Clark, 1999).
Case management models vary significantly in methodology. However, most research has credited case management for increased psychiatric stability (Malone et al., 1999). The increased psychiatric stability has been evidenced by increased independence, residential stability, vocational and social functions, decreased inappropriate use of emergency services, appropriate use of community services, and increased adherence of clients to medication and aftercare regimens (Malone et al., 1999).
Although there are numerous case management models in existence, four important models related to psychiatric-mental health nursing are presented here.
Multiple case management models exist with the PMHN assuming the role of a primary case manager or functioning as part of a case management team in collaboration with other health professionals. Services provided by the PMHN case manager can range from initiating the service to providing clinical case management.
Inpatient Model
The INPATIENT PSYCHIATRIC CASE MANAGEMENT MODEL originated at Waltham Weston Hospital in the emergency department (Herrick & Bartlett, 2004). In this model, psychiatric patients presenting to the hospital’s emergency department were assigned to a MANAGED CARE AGENT. This agent, a psychiatrist, therapist, or other psychiatric clinician, performed the initial assessment and initiated the treatment plan. The managed care agent also became part of a treatment team. In addition, the agent acted as the patient’s advocate, assisting with accessing appropriate inpatient or outpatient services, including crisis intervention, inpatient hospitalization, respite care, or partial hospitalization. These services were based on the needs of the patient. At the same time, the managed care agent also had to balance care costs and quality. Moreover, the agent was responsible for the patient 24 hours a day, 7 days a week. The sustained consistent relationship associated with this case management model required strong interpersonal process skills.
Continuum of Care Model
The continuum of care model, also known as the COLORADO MODEL, was developed at the University of Colorado Health Sciences Center (Herrick & Bartlett, 2004). This psychiatric case management model combined focused therapy (therapy aimed at intense frequent therapeutic engagement of the individual patient), assertive community treatment (ACT; individualized services available 24 hours a day based on needs delivered by a team of practitioners to the patients where they live), and family-centered interventions (services aimed at working with the patient from family systems perspective). Its goal was to rapidly transition hospitalized patients back into the community setting. The patient’s treatment plan was developed by the patient, the patient’s family, and the treatment team and was based on the assessed needs of the patient. The case manager guides the patient and family across the continuum of care, assisting the patient in accessing appropriate treatment. The case manager also coordinates the multidisciplinary team and monitors and documents the patient’s progress.
Broker Case Management Model
Community mental health centers employ multiple case management models. The BROKER CASE MANAGEMENT MODEL was developed in the 1960s and 1970s. In this model, brokering case managers, typically single individuals, are responsible for referral, placement, and monitoring of patients (Neale & Rosenheck, 1995). They provide little services themselves. Rather, they assess a patient’s needs and arrange for services from other providers to meet the patient’s needs. Brokering case managers may have large caseloads—100 patients or more (Malone et al., 1999). Many community mental health centers have combined the broker model with the disease management model to provide service to the chronic mentally ill (Herrick & Bartlett, 2004). The disease management model focuses on medical or somatic management of symptoms and relies on early detection of decompensation by the medical or somatic team.
Community mental health psychiatric case management services target patients’ needs to support independent living across the life span. Psychiatric services include crisis intervention, psychotherapy, family support, and medication management. Community mental health psychiatric case management recognizes the integrated role nonpsychiatric case management services play in chronic mentally ill clients’ well-being. Accordingly, assistance with housing, vocational training, and rehabilitative services are included under the model’s umbrella of services (Herrick & Bartlett, 2004).
Clinical Case Management
CLINICAL CASE MANAGEMENT is a worker-intensive, clinical case management model. The individuals commonly have the greatest need for services. The PMHN may work as the primary clinician or in collaboration with other health professionals in the community setting. The clinical case manager’s care is based on the level and type of services provided (Malone et al., 1999). Research suggests that the optimal case manager-to-client ratio ranges from 1:12 to 1:15 (Harris & Bergman, 1988).
Intensive clinical case management may include multidisciplinary, assertive, team-based support services in the community. Although services may vary, typically 24-hours-a-day, 7-days-a-week access to a multidisciplinary staff is provided. Round-the-clock, supportive telephone access and crisis intervention may be included (Borland, McRae, & Lycan, 1989; McRae, Higgins, Lycan, & Sherman, 1990).
Four models of psychiatric-mental health case management include the inpatient psychiatric case management model, the continuum of care psychiatric case management model, the broker model, and the clinical case management model.
CASE MANAGEMENT PROCESS
For case management to be successful, individuals at risk must be identified early and then appropriately stratified according to need (Moreo & Llewellyn, 2005). Case management services, therefore, must focus on the needs of the individual. Cooperation and partnership between the case manager and the individual and his or her family are essential to the case management process to promote increased compliance with the treatment plan (Moreo & Llewellyn, 2005). Box 7-2 highlights the key characteristics of case management.
In response to an individual’s health care problem, case managers are able to organize and sequence services (Knollmeuller, 1989). Ultimately, case management should enhance self-care and self-determination, provide continuity of appropriate care, maximize independence by enhancing functional capacity, and coordinate existing and new services to best serve the patient’s needs (White, 1986).
The case management process requires an interactive relationship that views the patient holistically and fosters empowerment through advocacy and education.
Goals and Principles of Case Management
The goal of case management is to provide individualized and holistic services to individuals at risk. The services should enhance self-care across the continuum of all health care services provided to a patient (Moreo & Llewellyn, 2005). Spanning the continuum of services provided, the discipline of case management is dynamic and interactive. It requires a high level of interaction with the patient and his or her family as well as among clinicians from multiple disciplines. Strong interpersonal skills are essential for building relationships with diverse individuals to provide service (Moreo & Llewellyn, 2005).
Overall, case management should “ensure the continuity of care between all points of care” (Mayer, 1996). Components of this overall goal include early detection and intervention, interdisciplinary communication and care planning, resource use to meet the patient’s needs, formation of strong alliances between families and health care professionals, and social support and health education. To achieve this outcome, the National Association of Case Management (NACM, 1997) identified principles for service provision that addressed consumer-focused case management and other community support for adults with severe and persistent mental illness. These principles are highlighted in Box 7-3.
BOX 7-2: KEY CHARACTERISTICS OF CASE MANAGEMENT
• Relationship based
• Interactive with patient and others
• Holistic
• Patient empowerment through advocacy
• Information provision through education
BOX 7-3: PRINCIPLES OF CASE MANAGEMENT FOR ADULTS WITH SEVERE AND PERSISTENT MENTAL ILLNESS
According to the NACM, to achieve the goal of case management, services provided should be:
• Consumer-focused
• Empowering for patients
• Racially and culturally appropriate
• Flexible
• Strength-focused
• Normalizing, incorporating natural supports
• Capable of meeting special needs
• Accountable
From the National Association of Case Management (NACM, 1997).
The end result of case management would be achievement of positive health outcomes through the delivery of coordinated, cost-effective, high-quality care. This care “enhances independent living capability and maximizes the quality of life of patients” (Mayer, 1996).
Necessary Skills for Case Management
The PMHN case manager integrates four critical skills to carry out the process of case management. These skills are critical thinking, communication, negotiation, and collaboration.
Critical Thinking
Critical thinking, as described in Chapter 5, refers to a purposeful method of reasoning that is systematic, reflective, rational, and outcome oriented. PMHNs use critical thinking as a basis for clinical decision making to plan and implement the most effective interventions for a patient.
PMHN case managers use critical thinking to sort through the myriad of information about a patient and the situation. Critical thinking is reflected by determining what information is pertinent and relevant; what, if any, additional information is needed; why certain events occurred or did not occur; and what the potential issues and problems are. For example, after sorting through information from the medical record and patient interview, the case manager realizes that information about the patient’s medication use has gaps. The case manager would investigate further to determine exactly what information is missing, such as if a medication was prescribed but not taken, and why.
From the information gathered, the PMHN case manager prioritizes the information and identifies relevant problems. Together with the patient, family, and other disciplines, options are explored, planned, and put into action. Throughout the process, the PMHN case manager continually evaluates the plan and activities, adapting, readjusting, or altering the plan based on changes that have occurred.
Communication
Communication is essential for the case management process (see Chapter 3 for a more in-depth discussion of communication skills). The PMHN case manager requires astute communication skills to obtain from and deliver information to the patient, patient’s family, other disciplines, and service providers. A sample interaction is illustrated in Therapeutic Interaction 7-1. For example, as a case manager for a patient with a chemical dependency history, the case manager may be involved in transporting the patient to the dentist for some procedures. The patient says, “If I get my tooth pulled, I hope they give some pain meds.” The psychiatric case manager might respond, “Well, I think they are likely to offer you something. With your history of addiction, what do you think would be best to accept?”
The PMHN case manager needs to be succinct and clearly articulate both verbally and in writing essential information. He or she acts as the central hub for communication, ensuring that information is shared clearly, accurately, and in a timely and efficient manner among all parties involved.
Negotiation
Negotiation is another essential skill required for effective case management. The PMHN case manager interacts with numerous individuals and parties involved in the patient’s care. He or she must be able to look at the “big picture” fairly and objectively, balancing the demands and needs of all the parties involved to ensure that the best outcome for the patient is achieved. For example, a case manager for a patient who needs to attend 10 Alcoholic Anonymous meetings a month per court order may negotiate transportation to and from five of the meetings each month with the patient’s sponsor. Or the case manager may be able to obtain bus tokens from the local transportation office so that the patient can ride the bus to and from the meetings. Mediation and compromise are fundamental to negotiation and resolution of the issues and problems.
