Case Management in Mental Health in the United States

Abstract

Case management is a core service for people with severe mental illnesses and an integral part of community-based mental health services. The service is part of the broader field of case management within social service settings but should be distinguished from case management in managed care, which focuses on utilization review rather than service provision. Case management evolved in response to the acute need to provide comprehensive supports for people in the community after deinstitutionalization. Designed to be the “glue” that holds together the complex and fragmented array of social services, case managers engage people in services and help them navigate the service system. Case management has been defined broadly as “the process of accessing, coordinating, and ensuring the receipt of services to assist individuals with psychiatric disabilities to meet their multiple and complex needs in an effective and efficient manner”. Case managers can also be referred to as service coordinators to avoid the implication that the people receiving services are “cases.” They work primarily in the community, engaging consumers, building relationships, and collaborating with them to meet their needs, which can include housing, benefits, mental health and health, and social support. Settings for case managers are primarily community mental health clinics, but can include substance abuse agencies, supportive housing programs, and hospitals. Case managers can be paraprofessionals or master’s level professionals from a variety of backgrounds, including social work, psychology, and psychiatric rehabilitation. Although they may have limited training, case managers are usually supervised by an experienced professional with master’s level training. One study found that over half of case managers have a bachelor’s degree, and three-quarters of supervisors have master’s degrees. There are various models of case management, including broker, clinical, Assertive Community Treatment (ACT), intensive case management, and rehabilitation. These models differ in respect to their practice and theoretical orientation, philosophy and values, and service intensity. Medicaid predominantly funds case management services under the categories of targeted case management or rehabilitative services. The seminal research on case management, much of which was conducted in the 1980s and the 1990s, has reflected a traditional mental health framework and therefore, has focused on its effectiveness in reducing hospitalization rates. Assertive community treatment, the most widely researched of the case management models, particularly had to demonstrate cost savings as its intensity and multidisciplinary approach make it a high-cost intervention. Positive findings prompted the widespread adoption of case management in the United States and globally, but still there remains debate about how case management impacts people’s quality of life. More recent research has focused on aspects of the service that are more consumer-oriented, including mental health recovery. As with many evidence-based practices, there are challenges in its translation to routine mental health settings, including fidelity to the model, level of training and skills among case managers, job stress, and high rates of turnover.