esetmenedzsment modellek/ case management
Az amerikai case management kifejezésből általában esetmenedzsmentként fordított tevékenység sok tekintetben leginkább a magyar szociális ellátórendszerben közösségi ellátás néven nevesített szolgáltatásnak felel meg.
Ez azonban csak fenntartásokkal igaz, mert az alábbiakban látni fogjuk, hogy a case management esetmenedzsment egyáltalán nem egységes gyakorlat, inkább sok megközelítést, programot, iskolát összefoglaló gyűjtőnév.
A különböző esetmenedzsment-modellekről többek között az ún. Schizophrenia Bulletin-ben jelent meg átfogó tanulmány (Mueser, Bond, Drake, Resnick, 1998). A tanulmány az egyes modelleket az alábbi logika mentén foglalja össze:
Közvetítői esetmenedzsment-modell (Broker Service Model)
Az első próbálkozások a különböző ellátórendszerek közötti tájékozódást szolgálták. Ez az ún. közvetítő modell. Az ilyen típusú esetmenedzseri tevékenység feladata a különböző intézmények közötti közvetítés, valamint a páciensek és a számukra szükséges szolgáltatások közötti kapcsolat kialakítása. (Moore, 1990)
Klinikai esetmenedzsment-modell
Ezt a kezdeményezést az a felismerés hozta létre, hogy a közvetítésen felül az esetmenedzsernek gyakran a direkt szolgáltatások nyújtásában is részt kell vennie. (Kanter, 1989) A modell szerint ez az alábbi területeken történik:
• kezdeti fázis (felvétel, értékelés, tervezés)
• környezeti intervenciók (összekapcsolás a közösségi forrásokkal, családtagokkal és más személyekkel folytatott konzultáció, együttműködés orvosokkal és kórházakkal, érdekképviselet)
• a pácienst érintő beavatkozások (egyéni pszichoterápia, készségfejlesztő tréningek, kommunikációfejlesztő tréningek, pszichoedukáció)
• páciens–környezet intervenciók (krízisintervenció, monitorozás)
Asszertív közösségi modell (Assertive Community Treatment Model, ACT)
Átfogó kezelést céloz meg, amely túlmutat mind a broker, mind pedig a klinikai modell keretein (Stein és Test, 1980). Team-munkáról van szó, melynek tagjai pszichiáter, ápoló és legkevesebb két esetmenedzser (rendszerint szociális munkás). A modell alapvető jellemzői:
Átfogó kezelést céloz meg, amely túlmutat mind a broker, mind pedig a klinikai modell keretein (Stein és Test, 1980). Team-munkáról van szó, melynek tagjai pszichiáter, ápoló és legkevesebb két esetmenedzser (rendszerint szociális munkás). A modell alapvető jellemzői:
• alacsony páciens-stáb ráta (10:1)
• a legtöbb szolgáltatást a közösségben nyújtják
• az esetek nem egyéni esetek, hanem az egész team együttesen viseli a felelősséget
• 24 órás elérhetőség
• a legtöbb szolgáltatást közvetlenül a team nyújtja, ritka a közvetítés
• a szolgáltatás időben nem korlátozott.
Intenzív esetmenedzsment modell (Intensive Case Management Model, ICM)
Ennek a modellnek a fejlődése a nagy szolgáltatásigényű használók szükségleteire reagálva indult meg (részletesebben Shern et al., 1989). A koncepció lényege, hogy ha az érintettek nem kapnak intenzív támogatást, akkor valószínűleg költségesebb szolgáltatásokat vesznek majd igénybe, például a sürgősségi ellátás figyelőszobáit (Surles és McGurrin, 1987). Ezt a modellt is alacsony páciens/stáb ráta jellemzi, s nem csupán teljes körű szolgáltatásokat nyújt a páciensek környezetében, hanem a munkatársak aktívan részt vesznek a napi életvezetésben is. (Aberg, Wistedt et al., 1995)
Erősség-modell (Strengths Model)
Ez a megközelítés az esetmenedzsment gyengeségeire adott válaszként jött létre. (Sullivan, 1992) Képviselői szerint a gyakorlatban túlhangsúlyozzák a károsodásokat, ami azzal jár, hogy elterelődik a figyelem a páciensek erősségeiről, amelyeket használni tud egyéni céljainak elérése érdekében. A megközelítés alapelvei (Rapp, 1993):
• inkább az egyéni erősségekre fókuszál, mint a patológiára
• az esetmenedzser-páciens kapcsolat elsődleges és alapvető
• az intervenciók a páciens önmeghatározásán alapulnak
• a közösségre úgy tekintenek, mint a források egy oázisára, és nem mint akadályra
• a pacienssel való kapcsolat a közösségben folyik, nem az irodában
• a súlyos mentális problémában szenvedő emberek folyamatosan képesek a tanulásra, fejlődésre és a változásra
Rehabilitációs-modell (Rehabilitation Model)
Ez a modell is inkább a páciens kívánságaira és céljaira helyezi a hangsúlyt, mint az egészségügyi ellátó rendszer céljaira. (Anthony et al., 1993) Különös jellemzője ennek a modellnek a készségek felmérése és fejlesztése, melyek segíthetik a közösségi létet és az egyéni célok elérését.
A szerzők megállapítása szerint a különböző modellek felbukkanása az elmúlt pár évtizedben tekinthető úgy is, mint egy természetes, evolúciós folyamat a mentálisan súlyosan beteg személyek ellátásában. Mielőtt elindult volna a dezinstitucionalizáció, nem volt szükség esetmenedzserre, a legtöbb páciens kórházban volt, ahol megőrző jellegű kezelést kapott. Amikor a páciensek visszatértek a közösségbe, kifejlődött a közvetítő (broker) modell, amely összekapcsol a szükséges kezelési és rehabilitációs forrásokkal. Ennek a szerepnek a bonyolultsága ahhoz a felismeréshez vezetett, hogy az esetmenedzsernek szüksége van egy sor klinikai készségre a páciens állapotának eredményes felmérése érdekében. Ezeknek a készségeknek a birtokában természetszerűleg jelentkezett az esetmenedzser részvétele a klinikai munkában (klinikai modell). Maga az esetmenedzser terepen végzett tevékenysége azonban felvetette a szolgáltatások közösségben történő nyújtásának kérdését (asszertív és intenzív modellek). Részben az eredmények folyamatos monitorozása és a korábbi modellek hiányosságai következtében jöttek létre az erősség (strenghts) és rehabilitációs modellek.
A különböző esetmenedzsment-modellek eredményességét vizsgálva az ACT és az ICM modellek emelkedtek ki. A legkomolyabb pozitív változást a kórházban töltött idő csökkenésében, a lakóhelyi stabilitásban való előrelépésben, az életminőség javulásában, s a páciensek és hozzátartozók elégedettségében lehetett megfigyelni (Mueser et al., 1998).
Esetmenedzsment szolgáltatások (példák)/ case management services (samples)
Capital District Mental Health Program
The Mental Health Program Case Management Services are examples of Best Practice in psychiatric rehabilitation. They provide a range of case management services based on two models, Assertive Community Treatment ( ACT ) and Intensive Case Management. The teams provide service to individuals living in the community with a severe and persistent mental illness or concurrent mental illness and substance abuse which has had a major impact on aspects of their lives, such as housing, employment, social supports, finances, daily living skills.
The teams operate under the Principles of Psychosocial Rehabilitation which emphasize hope, recovery, empowerment, and effective rehabilitation founded on a partnership between the person receiving services and the practitioner. The goal of the teams is to support individuals in achieving the best quality of life possible and to support individuals in their recovery and growth beyond illness.
Rochester Rehabilitation Center
Case Management is a service for participants in the Mental Health and Vocational Services programs, who need support and assistance with:
* Linkage to housing options
* Financial entitlement programs (Social Security and Department of Social Services)
* Transportation
* Physical and dental health care
* Budgeting
The goal of the program is to promote independent living, self-sufficiency, and assist individuals in improving their quality of life.
The services are tailored to individual needs.
Irodalom/Literature
Aberg-Wistedt, A.–Cresell, T.–Lindberg, Y.–Liljenberg, B.–Ösby, U. (1995): Two-year outcome of team-based intensive case management for patients with schizophrenia. Psychiatric Services, 46:1263–1266.
OBJECTIVES: Two-year outcomes of patients with schizophrenic disorders who were assigned to an intensive, team-based case management program and patients who received standard psychiatric services were assessed. The case management model featured increased staff contact time with patients, rehabilitation plans based on patients' expressed needs, and patients' attendance at team meetings where their rehabilitation plan was discussed. METHODS: Forty patients were randomly assigned to either the case management group or the control group that received standard services. Patients' use of emergency and inpatient services, their quality of life, the size of their social networks, and their relatives' burden of care were assessed at assignment to the study groups and at two-year follow-up. RESULTS: Patients in the case management group had significantly fewer emergency visits compared with the two years before the study, and their relatives reported significantly reduced burden of care associated with relationships with psychiatric services over the two-year period. The size of patients' social networks increased for the case management group and decreased for the control group. CONCLUSIONS: A team-based intensive case management model is an effective intervention in the rehabilitation of patients with chronic schizophrenia.
Anthony, W. A.–Cohen, M. R.–Farkas, M.–Cohen, B. F. (1988): Clinical care update: The chronically mentally ill. Case management-More than a response to a dysfunctional system. Community Mental Health Journal, 24:219–228.
Abstract The service systems which assist the long-term mentally ill to function in the community have been routinely described as fragmented and uncoordinated. The development and implementation of case management has been seen as one response to this dysfunctional system. This article examines case management from the perspective that case management is a needed function no matter how coordinated and integrated the system.
From this perspective, case management is driven by the clients' goals and not the systems' goals. Case management is viewed as a process by which the person with severe psychiatric disability is supported in negotiating for the various services that they want and need. Four unique activities are identified as performed by the case manager: Connecting with Clients, Planning for Services, Linking Clients with Services, and Advocating for Service Improvements.
Case management must be seen as a uniquely human response to the client's specific service needs and overall goals. For persons with long-term psychiatric disabilities, case management brings to life the human dimension of the human service system.
Bigelow, Douglas A. Ph.D. and Young,Deborah J. R.N., M.N. (1991): Effectiveness of a Case Management Program. Community Mental Health Journal, Vol. 27, No. 2, April 1991
ABSTRACT: Legislation of a case management service provided an opportunity to conduct a natural experiment exploring questions about implementation and effectiveness of case management services. A sample of 21 case managed and 21 comparison clients was interviewed using a protocol adapted from the Quality of Life Questionnaire (Fixed Response Alternative version). Results indicate that case managed clients received more services and had fewer unmet service needs. Quality of life was greater for case managed clients, hospital utilization was reduced, and a possible relationship among services, quality of life, and hospital utilization was identified.
Corrigan, Patrick W. and Kayton-Weinberg, Donna (1993) “Aggressive” and “problem-focused” models of case management for the severely mentally ill. Community Mental Health Journal Volume 29/ Number 5/October 1993 449-458
Abstract In this paper, the relative merits and limitations of two models of case management (CM) are compared: aggressive and problem-focused . Although aggressive CM has a well-established history of improving the community tenure of deinstitutionalized patients, individuals participating in this treatment are likely to become dependent on health care providers and hence require indeterminate assistance. Problem-focused CM teaches patients how to identify and resolve community-based predicaments thereby making them relatively more independent of the mental health system. Patients receiving problem-focused CM, however, need reasonably competent cognitive functions thereby ruling out participation of the most severely disabled individuals. An interaction of the two approaches is proposed in which aggressive and problem-focused CM is selected depending on the patient''s current needs, cognitive deficit, and level of social support.
Kanter, J. (1989): Clinical case management: Definition, principles, components. Hospital and Community Psychiatry, 40:361–368.
The burgeoning field of case management for long-term psychiatric patients has been handicapped by a lack of conceptual models that delineate the diverse activities of case managers. Based on the actual practice of case management, the author outlines a model of clinical case management that moves beyond the view of the case manager as a systems coordinator, service broker, or supportive companion. Using a contemporary biopsychosocial model of mental illness, the clinical case management model integrates the clinical acumen, personal involvement, and environmental interventions needed to address the overall maintenance of the patient's physical and social environment. Clinical case management involves 13 distinct activities, including engagement of the patient, assessment, planning, linkage with resources, consultation with families, collaboration with psychiatrists, patient psychoeducation, and crisis intervention.
Longhofer, Jeffrey; Floersch, Jerry; Jenkins, Janis H. Medication Effect Interpretation and the Social Grid of Management Social Work in Mental Health Vol. 1, No.4, 2003, pp. 71-89
SUMMARY. This article reports on two research projects and argues that current medication management research and practice does not represent the complexity of community-based psychotropic treatment. Ethnographic findings are used to demonstrate that a social grid of management exists to negotiate medication ‘effect’ interpretation. Anthropological and semi-structured interview data are used to illustrate patient subjective experience of atypical antipsychotic treatment. It is argued that ‘active’ and ‘passive’ management relationships are produced by the myriad ways individuals manage the gap between the desired and actual effects of medication. It is shown that psychological and cultural ‘side effects’ are as common as physical ‘side effects.’
Moore, S. (1990): A social work practice model of case management: The case management grid. Social Work, 35:444–448.
Mueser, K. T.–Bond, G. R.–Drake, R. E.–Resnick, S. G. (1998): Models of Community Care for Severe Mental Illnes: A review of Research on Case Managment. Schizophrenia Bulletin 24(1) 37:74, National Institute of Mental Health.
OBJECTIVES: Two-year outcomes of patients with schizophrenic disorders who were assigned to an intensive, team-based case management program and patients who received standard psychiatric services were assessed. The case management model featured increased staff contact time with patients, rehabilitation plans based on patients' expressed needs, and patients' attendance at team meetings where their rehabilitation plan was discussed. METHODS: Forty patients were randomly assigned to either the case management group or the control group that received standard services. Patients' use of emergency and inpatient services, their quality of life, the size of their social networks, and their relatives' burden of care were assessed at assignment to the study groups and at two-year follow-up. RESULTS: Patients in the case management group had significantly fewer emergency visits compared with the two years before the study, and their relatives reported significantly reduced burden of care associated with relationships with psychiatric services over the two-year period. The size of patients' social networks increased for the case management group and decreased for the control group. CONCLUSIONS: A team-based intensive case management model is an effective intervention in the rehabilitation of patients with chronic schizophrenia.
Anthony, W. A.–Cohen, M. R.–Farkas, M.–Cohen, B. F. (1988): Clinical care update: The chronically mentally ill. Case management-More than a response to a dysfunctional system. Community Mental Health Journal, 24:219–228.
Abstract The service systems which assist the long-term mentally ill to function in the community have been routinely described as fragmented and uncoordinated. The development and implementation of case management has been seen as one response to this dysfunctional system. This article examines case management from the perspective that case management is a needed function no matter how coordinated and integrated the system.
From this perspective, case management is driven by the clients' goals and not the systems' goals. Case management is viewed as a process by which the person with severe psychiatric disability is supported in negotiating for the various services that they want and need. Four unique activities are identified as performed by the case manager: Connecting with Clients, Planning for Services, Linking Clients with Services, and Advocating for Service Improvements.
Case management must be seen as a uniquely human response to the client's specific service needs and overall goals. For persons with long-term psychiatric disabilities, case management brings to life the human dimension of the human service system.
Bigelow, Douglas A. Ph.D. and Young,Deborah J. R.N., M.N. (1991): Effectiveness of a Case Management Program. Community Mental Health Journal, Vol. 27, No. 2, April 1991
ABSTRACT: Legislation of a case management service provided an opportunity to conduct a natural experiment exploring questions about implementation and effectiveness of case management services. A sample of 21 case managed and 21 comparison clients was interviewed using a protocol adapted from the Quality of Life Questionnaire (Fixed Response Alternative version). Results indicate that case managed clients received more services and had fewer unmet service needs. Quality of life was greater for case managed clients, hospital utilization was reduced, and a possible relationship among services, quality of life, and hospital utilization was identified.
Corrigan, Patrick W. and Kayton-Weinberg, Donna (1993) “Aggressive” and “problem-focused” models of case management for the severely mentally ill. Community Mental Health Journal Volume 29/ Number 5/October 1993 449-458
Abstract In this paper, the relative merits and limitations of two models of case management (CM) are compared: aggressive and problem-focused . Although aggressive CM has a well-established history of improving the community tenure of deinstitutionalized patients, individuals participating in this treatment are likely to become dependent on health care providers and hence require indeterminate assistance. Problem-focused CM teaches patients how to identify and resolve community-based predicaments thereby making them relatively more independent of the mental health system. Patients receiving problem-focused CM, however, need reasonably competent cognitive functions thereby ruling out participation of the most severely disabled individuals. An interaction of the two approaches is proposed in which aggressive and problem-focused CM is selected depending on the patient''s current needs, cognitive deficit, and level of social support.
Kanter, J. (1989): Clinical case management: Definition, principles, components. Hospital and Community Psychiatry, 40:361–368.
The burgeoning field of case management for long-term psychiatric patients has been handicapped by a lack of conceptual models that delineate the diverse activities of case managers. Based on the actual practice of case management, the author outlines a model of clinical case management that moves beyond the view of the case manager as a systems coordinator, service broker, or supportive companion. Using a contemporary biopsychosocial model of mental illness, the clinical case management model integrates the clinical acumen, personal involvement, and environmental interventions needed to address the overall maintenance of the patient's physical and social environment. Clinical case management involves 13 distinct activities, including engagement of the patient, assessment, planning, linkage with resources, consultation with families, collaboration with psychiatrists, patient psychoeducation, and crisis intervention.
Longhofer, Jeffrey; Floersch, Jerry; Jenkins, Janis H. Medication Effect Interpretation and the Social Grid of Management Social Work in Mental Health Vol. 1, No.4, 2003, pp. 71-89
SUMMARY. This article reports on two research projects and argues that current medication management research and practice does not represent the complexity of community-based psychotropic treatment. Ethnographic findings are used to demonstrate that a social grid of management exists to negotiate medication ‘effect’ interpretation. Anthropological and semi-structured interview data are used to illustrate patient subjective experience of atypical antipsychotic treatment. It is argued that ‘active’ and ‘passive’ management relationships are produced by the myriad ways individuals manage the gap between the desired and actual effects of medication. It is shown that psychological and cultural ‘side effects’ are as common as physical ‘side effects.’
Moore, S. (1990): A social work practice model of case management: The case management grid. Social Work, 35:444–448.
Mueser, K. T.–Bond, G. R.–Drake, R. E.–Resnick, S. G. (1998): Models of Community Care for Severe Mental Illnes: A review of Research on Case Managment. Schizophrenia Bulletin 24(1) 37:74, National Institute of Mental Health.
Preston, Neil Joseph; Fazio Sam (2000) Establishing the efficacy and cost effectiveness of community intensive case management of long-term mentally ill: a matched control group study Australian and New Zealand Journal of Psychiatry 34 (1), 114–121.
Objective: The study attempted to identify whether chronic mentally ill persons after receiving intensive case management (ICM) could demonstrate improved inpatient service utilisation compared with a matched control group cohort. Costings were measured to observe whether the increase in providing intensive outpatient contacts would be offset by savings in reduced inpatient service utilisation.
Method: Eighty ICM patients were matched on ICD-9 diagnosis, age, gender, length of illness, age at first inpatient and outpatient contact, marital status, educational level, employment status, country of birth, year of arrival to Australia and religion. Inpatient bed-days and outpatient contacts were recorded and compared 12 months prior to ICM treatment, 12 and 24 months after ICM using within/between group repeated measures analysis of variance.
Results: The ICM group demonstrate significant reductions in inpatient service utilisation both within the 12- and 24-month period after receiving ICM treatment. The cost differential by 24 months of treatment was $801 475 in favour of the ICM model. The increase in costs of outpatient contacts were offset by a significant reduction in inpatient service utilisation.
Conclusion: When outpatient contacts averaged one contact a week for the duration of the study period no significant reductions in inpatient service utilisation was recorded, as demonstrated by comparison with the matched control group. By increasing outpatient contacts by 3–4 contacts a week, inpatient contacts reduced by 36.8%. ICM is an efficacious and cost effective way to implement community-based services to the chronically long-term mentally ill.
Rapp, C. A. (1993): Theory, principles, and methods of the strengths model of case management. In: Harris, M., and Bergman, H. C., (szerk.): Case Management for Mentally Ill. Patients: Theory and Practice. Langhorne, PA: Harwood Academic Publishers, 1993. 143–164.
Rhode D. (1997):Evolution of community mental health case management: considerations for clinical practice. Arch Psychiatr Nurs. 1997 Dec;11(6):332-9.
Case management has been the preferred method of helping persons with mental illness live in the community. This report examines the historical development of case management practice over the past 30 years. The analysis revealed that evolutionary growth in case management developed in response to expansion of community mental health services rather than consumer interests to improve their quality of life. Consequently, this reveals itself in the lack of outcome criteria needed to measure case management effectiveness. Currently, the concept of case management is undergoing a revolutionary paradigm shift that is "consumer-driven" and responds to consumer concerns. However, as mental health care costs rise within a rapidly growing community mental health care system, managed care is being implemented as a method to contain these rising costs. Because of major differences in philosophical underpinnings, developments in support of public mental health managed care may jeopardize the genesis of consumer-driven case management by supporting case management models that reflect managed care ideology.
Sullivan, W. P. (1992): Reclaiming the community. The strengths perspective and deinstitutionalization. Social Work, 37:204–209.
Surles, R.C.–McGurrin, M.C. (1987): Increased use of psychiatric emergency services by young chronic mentally ill. patients. Hospital and Community Psychiatry, 38:401–405.
Shern, D. L.–Surles, R. C.–Waizer, J. (1989): Designing community treatment systems for the most seriously mentally ill: A state administrative perspective. Journal of Social Issues, 45:105–117.
Smith Gregory B.; Ryan Andrew I.; Schwebel L. Dunn; McIver Stephanie D. (1993) The Role of Psychologists in the Treatment, Management, and Prevention of Chronic Mental Illness American Psychologist, September 1993 Vol. 48, No. 9, 966-971
In addition to suffering from the severe psychiatric symptoms of chronic mental illness (CMI), people with this type of disorder suffer from a variety of secondary disabilities and face societal obstacles that interfere with their ability to maximize their personal, social, and vocational potentials. Following the deinstitutionalization of long-term psychiatric patients in recent decades, many different understandings of the etiology, treatment, and management of CMI have evolved, including those derived from the biological, vulnerability, cognitive, case management, rehabilitation, and psychoeducational models. Because psychologists are trained in a wide range of psychological theories and a broad repertoire of applications, they have unique contributions to make within each model, particularly, as discussed here, to prevent, treat, and manage CMI through research, assessment, and intervention.
Stein, L. I.–Test, M. A. (1980): Alternative to mental hospital treatment: I. Conceptual model, treatment program and clinical evaluation. Archives of General Psychiatry, 37:392–397.
Ziguras, Stephen J. , M.A. and Stuart, Geoffrey W. , Ph.D.(2000): A Meta-Analysis of the Effectiveness of Mental Health Case Management Over 20 Years. Psychiatr Serv 51:1410-1421, November 2000
OBJECTIVE: Meta-analytical methods were used to investigate the effectiveness of case management and to compare outcomes for assertive community treatment and clinical case management. METHODS: Controlled studies of case management published between 1980 and 1998 were identified from reviews and through database searches. The results were quantitatively combined and compared with results of studies of mental health services without case management. Combined effect sizes and significance levels for 12 outcome domains were calculated. Analysis of homogeneity was used to explore differences between models. RESULTS: Forty-four studies were analyzed; 35 compared assertive community treatment or clinical case management with usual treatment, and nine directly compared assertive community treatment with clinical case management. Both types of case management were more effective than usual treatment in three outcome domains: family burden, family satisfaction with services, and cost of care. The total number of admissions and the proportion of clients hospitalized were reduced in assertive community treatment programs and increased in clinical case management programs. In both programs the number of hospital days used was reduced, but assertive community treatment was significantly more effective. Although clients in clinical case management had more admissions than those in usual treatment, the admissions were shorter, which reduced the total number of hospital days. The two types of case management were equally effective in reducing symptoms, increasing clients' contacts with services, reducing dropout rates, improving social functioning, and increasing clients' satisfaction. CONCLUSIONS: Both types of case management led to small to moderate improvements in the effectiveness of mental health services. Assertive community treatment had some demonstrable advantages over clinical case management in reducing hospitalization.
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