Standard Case Management Research Articles

Intensive case management was not more cost effective than standard case management for severe psychosis

UK700 Group. Cost-effectiveness of intensive v standard case management for severe psychotic illness. UK700 case management trial. Br J Psychiatry2000 Jun; 176 : 537 –43 [OpenUrl][1][Abstract/FREE Full Text][2] QUESTION: In...

Standard case management of pneumonia in hospitalized children in Uruguay, 1997 to 1998.

To report the results of the use of antimicrobial guidelines for the management of children with community-acquired bacterial pneumonia. Admittance and discharge criteria and algorithms for diagnosis and treatment were established. The decision to treat with antibiotics was based on radiologic findings in pneumonia with pulmonary consolidation and left to the attending physician's criteria in the remaining cases. The use of antibiotics was limited to penicillin and derivatives (ampicillin, amoxicillin) and macrolides. Of the 1163 children treated as bacterial pneumonia, hospitalized in public and private health facilities in Montevideo from September, 1997, through September, 1998, standard case management was applied in 1082 (93%). Age distribution was: <1 month, 1%; between 1 and 11 months, 29%; between 1 and 5 years, 50%; >5 years, 20%. Chest radiography showed evidence of pulmonary consolidation in 843 children (73%). Bacteria were detected in blood culture and/or pleural fluid of 57 children (5%). In 51 the identified microorganism was Streptococcus pneumoniae, susceptible to penicillin in 30, intermediate in 6 and resistant in 5 (maximum MIC, 4 microg/ml); in 10 cases etiologic diagnosis was made by antigen detection. Empyema was present in 62 children (5.3%); 38 (3.27%) required treatment in an intensive care unit; and 5 (0.4%) died. Compliance with standard case management was highly satisfactory. Outcome of children treated with penicillin and derivatives was good, including children with empyema and pneumatocele and two patients with penicillin-resistant S. pneumoniae. At the present time S. pneumoniae resistant to penicillin is not an important problem in children with pneumonia in Uruguay. Surveillance of identified microorganisms and their antimicrobial susceptibility must continue.

Improving private practitioner care of sick children: testing new approaches in rural Bihar.

Private practitioners are a major source of care for childhood illnesses in developing countries, but the care they provide is often of poor quality. This study tested the effectiveness of two new methods for improving the quality of private practitioner care of sick children: the verbal case review (VCR) and INFECTOM. The VCR is a method for evaluating private providers' quality of care based on mothers' reports and INFECTOM is a package of interventions for improving private providers' quality of care. The study was conducted in 110 villages of Bihar State, India, by three local non-governmental organizations (NGOs). First, the VCR was used for interviews with mothers of approximately 600 children sick with diarrhoea, ARI or fever in the past 2 weeks. The VCR identified practitioners consulted for the treatment of the sick children and recorded providers' case management practices as reported by the mothers. Based on the results of the VCR, the INFECTOM intervention was carried out. This consisted of INformation sessions for the providers regarding standard case management guidelines for ARI, diarrhoea and fever, FEedback to providers on their performance based on the results of the VCR, ConTracting with practitioners to gain their commitment to practice specific guidelines, and Ongoing Monitoring of practitioners' practices with feedback of the results to the practitioners and the community. Seven months after the interventions were initiated, another cross-sectional VCR survey of approximately 300 sick children was carried out to evaluate the impact of the activities on practitioners' case management practices. The results of the study show statistically significant improvements in private practitioners' history taking, examination and counselling practices for ARI, diarrhoea and fever. It was concluded that the VCR and INFECTOM were feasible for implementation by community-based NGOs, and were effective in improving the technical quality of care provided by private health practitioners in rural India.

Measuring disability, need and outcome in Australian community mental health services

Objective: This study trialled routine measurement of disability, need and outcome in mental health services within Sydney. Method: Fifteen community mental health clinicians with a combined caseload of 283 patients participated in the study. The Health of the Nation Outcome Scales (HoNOS) was used to assess disability and outcome and the patient and staff versions of the Camberwell Assessment of Need (CAN) were used to assess need. Results: The HoNOS and CAN appear to be promising contenders for routine use. Patients receiving assertive case management were rated as having higher levels of disability and need than patients receiving standard case management. Significant change in outcome was demonstrated with the HoNOS. Conclusions: To ensure the continued measurement of consumer outcome, issues such as staff education, training, and the development of computerised information systems should be addressed.

Measuring disability, need and outcome in Australian community mental health services.

This study trialled routine measurement of disability, need and outcome in mental health services within Sydney. Fifteen community mental health clinicians with a combined caseload of 283 patients participated in the study. The Health of the Nation Outcome Scales (HoNOS) was used to assess disability and outcome and the patient and staff versions of the Camberwell Assessment of Need (CAN) were used to assess need. The HoNOS and CAN appear to be promising contenders for routine use. Patients receiving assertive case management were rated as having higher levels of disability and need than patients receiving standard case management. Significant change in outcome was demonstrated with the HoNOS. To ensure the continued measurement of consumer outcome, issues such as staff education, training, and the development of computerised information systems should be addressed.

Personality abnormality in severe mental illness and its influence on outcome of intensive and standard case management: a randomised controlled trial

Personality abnormality in severe mental illness and its influence on outcome of intensive and standard case management: a randomised controlled trial

Personality abnormality in severe mental illness and its influence on outcome of intensive and standard case management: a randomised controlled trial

One hundred fifty-five (77%) of 201 participants recruited in a trial of intensive vs standard case management of patients with recurrent psychotic illness had their personality status measured before treatment and were followed up for two years. The primary outcome was the total number of days spent in psychiatric hospitalisation in the two years following randomisation. Thirty-three (21%) of the patients had a personality disorder and their duration of hospital stay (105 days) was greater than in those without personality disorder (56 days). There was weak evidence that intensive case management more effective in reducing the duration of care in those with personality disorder than in those without personality disorder.

Problems in developing an instrument for the rapid assessment of personality status

Purpose: To assess the validity of a quick assessment instrument (10 minutes) for assessing personality status, the Rapid Personality Assessment Schedule (PAS-R). Subjects and methods: The PAS-R was evaluated in psychotic patients recruited in one of the centres involved in a multicentre randomised controlled trial of intensive vs standard case management (the UK700 case management trial). Patients were assessed using both a full version of the PAS (PAS-I – ICD version) and the PAS-R. The weighted kappa statistic was used to gauge the (criterion-related) validity of the PAS-R using the PAS-I as the gold standard. Both measure code personality status using a four-point rating of severity in addition to recording individual categories of personality disorder. Results: One hundred fifty-five (77%) of 201 patients recruited were assessed with both instruments. The weighted kappa statistic was 0.31, suggesting only moderate agreement between the PAS-I and PAS-R instruments under the four-point rating format, and 0.39 for the dichotomous personality disorder/no disorder separation. The sensitivity (64%) and specificity (82%) of the PAS-R in predicting PAS-I personality disorder were as satisfactory as for other screening instruments but still somewhat disappointing, and the PAS-R had an overall diagnostic accuracy of 78%. Conclusion: The PAS-R is a quick and rough method of detecting personality abnormality but is not a substitute for a fuller assessment.

Intensive case management was as effective as standard case management in severe psychotic illness

Intensive case management was as effective as standard case management in severe psychotic illness

Assertive Community Treatment for Persons with Severe Mental Disorders: A Controlled Treatment Outcome Study

AbstractThe present study evaluated the efficacy of an Assertive Community Treatment (ACT) program for the seriously mentally ill. Outcomes of the program were assessed at baseline and 12-month follow-up and were compared with that of a control group, which received standard community care. Thirty-six subjects with serious mental disorders participated in the study. Dependent measures included number of hospital admissions and hospital bed days per year, life skills, quality of life, and psychiatric symptoms. Results of 2 x 2 (treatment/control group x baseline / 12-month follow-up) repeated measures ANOVAs indicated that, after 1 year, both treatments lead to a significant reduction in hospital admissions and bed days, and to improvement in life skills. ACT subjects evidenced a greater decrease in psychiatric symptoms compared to control group subjects. In general, markedly more ACT subjects showed reliable clinical change in life skills, quality of life, and psychiatric symptoms than control subjects. Although the ACT did produce greater clinical change than standard case management, it did not produce statistically greater improvement across most domains of functioning in the short term.

A study of client-focused case management and consumer advocacy: the Community and Consumer Service Project

Objective: The study investigated the provision of client-focused services to community-based clients with schizophrenia and bipolar disorder. It hypothesised that the delivery of more client-focused services would improve client outcome in terms of functioning, disability and satisfaction with services. Client-focused services were developed using an empowerment model of case management and by the addition of consumer advocates.Method: Clients referred for case management were randomly allocated to one of three groups: standard case management (n = 35), client-focused case management (n = 39), or client-focused case management plus consumer advocacy (n = 45). Measures of functioning, disability, quality of life, burden of care and service satisfaction were measured at baseline and 12 months. Outcome data were collected concerning number and duration of hospital readmission, crisis intervention and compliance with treatment and services.Results: While there were no differences between the groups on quantitative measures of functioning, disability, quality of life, service satisfaction and burden of care, there were significant between-group differences on qualitative measures of satisfaction with services.Conclusions: Several methodological difficulties hampered interpretation of the findings. Although clients did not differ on outcome measures of functioning and disability, the group receiving client-focused case management reported greater satisfaction with service delivery.

Intensive case management for psychotic patients with borderline intelligence

Patients with recurrent psychotic disorder and borderline learning disability who were randomly assigned intensive case management spent less than half the subsequent time in hospital than those who were assigned standard case management.

Intensive versus standard case management for severe psychotic illness: a randomised trial

Case management has increasingly been the recommended approach to care for severely mentally ill patients since the number of psychiatric beds has decreased. Despite equivocal results, in the UK and Europe, this approach is becoming accepted policy. We assessed the effect of smaller case loads. We randomly assigned 708 psychotic patients in four centres standard case management (355 patients, case load 30-35 per case manager) or intensive case management (353 patients, case load 10-15 per case manager). We measured clinical symptoms and social functioning at baseline, 1 year, and 2 years. The impact of treatment on hospital use was assessed at 2 years by subgroup analyses for Afro-Caribbean and for severely socially disabled patients. Analysis was by intention to treat. There was no significant decline in overall hospital use among intensive-case-management patients (mean 73.5 vs 73.1 days in those who received standard care [SD 0.4, 95% CI -17.4 to 18.1]), nor were there any significant gains in clinical or social functioning. There was no evidence of differential effect in Afro-Caribbean patients or the most socially disabled patients. In well-coordinated mental-health services, a decline in case load alone does not improve outcome for these patients. Mental-health planners may need to pay more attention to the content of treatment rather than changes in service organisation.

Signs of severe bacterial infection in neonates.

The objective of this study was to identify a short list of valid signs for the development of standard case management guidelines for severe bacterial infection (SBI) in newborn infants, an important cause of neonatal deaths in low-income countries. The reported and observed signs of 83 sick neonates admitted during 12 consecutive months were recorded. At discharge, 50 cases were classified, using predefined criteria, as SBI, mostly pneumonia, and 33 as other disease. The neonates with other diseases were significantly younger than those with SBI. None of the reported and observed signs, when used alone, had a high sensitivity, an important feature for a severe disease amenable to effective treatment. The best sensitivity (74 per cent) was obtained when a doctor observed severe chest indrawing or fast breathing or 'not looking well'; the specificity was 67 per cent and the positive predictive value 77 per cent. The sensitivity of reported difficult breathing and of observed severe chest indrawing, when measured only for the diagnosis of pneumonia, improved to 77 per cent, with a specificity of 84 per cent and 66 per cent, respectively. Reported fever and the observation that the neonate was 'not looking well' were the best independent predictors of SBI on logistic regression analysis. Simple standard case management (SCM) guidelines based only on reported and observed clinical signs would not identify the majority of neonates with SBI at primary health care level.

Assertive community treatment for people with severe mental disorders.

Assertive Community Treatment (ACT) was developed in the early 1970s as a response to the closing down of psychiatric hospitals. ACT is a team-based approach aiming at keeping ill people in contact with services, reducing hospital admissions and improving outcome, especially social functioning and quality of life. To determine the effectiveness of Assertive Community Treatment (ACT) as an alternative to i. standard community care, ii. traditional hospital-based rehabilitation, and iii. case management. For each of the three comparisons the main outcome indices were i. remaining in contact with the psychiatric services, ii. extent of psychiatric hospital admissions, iii. clinical and social outcome and iv. costs. Electronic searches of CINAHL (1982-1997), the Cochrane Schizophrenia Group's Register of trials (1997), EMBASE (1980-1997), MEDLINE (1966-1997), PsycLIT (1974-1997) and SCISEARCH (1997) were undertaken. References of all identified studies were searched for further trial citations. The inclusion criteria were that studies should i. be randomised controlled trials, ii. have compared ACT to standard community care, hospital-based rehabilitation, or case management and iii. have been carried out on people with severe mental disorder the majority of whom were aged from 18 to 65. Studies of ACT were defined as those in which the investigators described the intervention as "Assertive Community Treatment" or one of its synonyms. Studies of ACT as an alternative to hospital admission, hospital diversion programmes, for those in crisis, were excluded. The reliability of the inclusion criteria were evaluated. Three types of outcome data were available: i. categorical data, ii. numerical data based on counts of real life events (count data) and iii. numerical data collected by standardised instruments (scale data). Categorical data were extracted twice and then cross-checked. Peto Odds Ratios and the number needed to treat (NNT) were calculated. Numerical count data were extracted twice and cross-checked. Count data could not be combined across studies for technical reasons (the data were skewed) but all relevant observations based on count data were reported in the review. Numerical scale data were subject to a quality assessment. The validity of the quality assessment was itself assessed. Numerical scale data of suitable quality were combined using the standardised mean difference statistic where possible, otherwise the data were reported in the text or 'Other data tables' of the review. ACT versus standard community care Those receiving ACT were more likely to remain in contact with services than people receiving standard community care (OR 0.51, 99%CI 0.37-0.70). People allocated to ACT were less likely to be admitted to hospital than those receiving standard community care (OR 0.59, 99%CI 0.41-0.85) and spent less time in hospital. In terms of clinical and social outcome, significant and robust differences between ACT and standard community care were found on i. accommodation status, ii. employment and iii. patient satisfaction. There were no differences between ACT and control treatments on mental state or social functioning. ACT invariably reduced the cost of hospital care, but did not have a clear cut advantage over standard care when other costs were taken into account. ACT versus hospital-based rehabilitation services Those receiving ACT were no more likely to remain in contact with services than those receiving hospital-based rehabilitation, but confidence intervals for the odds ratio were wide. People getting ACT were significantly less likely to be admitted to hospital than those receiving hospital-based rehabilitation (OR 0.2, 99%CI 0.09-0.46) and spent less time in hospital. Those allocated to ACT were significantly more likely to be living independently (OR (for not living independently) 0.19, 99%CI 0.06-0. (A

Who is a heavy service user? Preliminary development of a screening instrument for prospective consumers of a mobile intensive treatment team.

The mobile intensive treatment team (MITT) of the Valley Integrated Adult Mental Health Service in Brisbane, Australia, aims to provide services in the community to people with severe and persistent mental illness who have traditionally been heavily reliant on inpatient services (i.e. heavy service users). The MITT screening instrument (MITTSI) was developed to provide an objective measure to appropriately identify patients for referral to the service. A literature review and a panel of multidisciplinary clinicians were consulted to identify a list of specific attributes that would assist in the detection of heavy service users. These attributes were then formulated into an easy-to-administer screening instrument entitled the MITTSI. The MITTSI was administered in an interview format to MITT case managers (intensive case management) and to case managers in standard case management with prospective MITT patients (prospective heavy service users). Analyses of the responses indicated support for the MITTSI as a valid screening instrument in identifying heavy service users and for determining appropriate patients for referral to the MITT. The MITTSI is an easy-to-administer screening instrument which provides clear guidelines for inclusion and exclusion, and is an objective measure regarding the patients' urgency for referral to the MITT. Follow-up of the MITTSI within a broader, longer-term project will attempt to further refine the MITTSI and to further determine its validity. Outcomes will be published at a later stage.

Mothers' perceptions of signs and symptoms of acute respiratory infections in their children and their assessment of severity in an urban community of Ethiopia.

Standard case management strategy has been recommended to reduce the high mortality rate in children with acute respiratory infections (ARI). Appropriate case management has been shown to prevent such deaths, but only if families recognize signs of possible pneumonia and seek care promptly from a trained health worker. The purpose of the present study was to assess mothers' perception and interpretation of ARI signs and symptoms in relation to that of a physician in an urban community in Addis Ababa. Two hundred and twenty-two mothers who brought their children to hospital with cough or difficulty in breathing and an equal number of control mothers were studied. Most mothers did not recognize these signs, including the key signs of pneumonia-rapid breathing and chest indrawing. While it was shown that between two physicians there was good agreement on kappa values above 70% for most ARI signs, there was little agreement between physicians and mothers or between mothers whose children came for ARI problems and mothers of hospital controls. The few mothers who recognized these signs did not interpret them as serious. The study concludes by recommending intensive health education and further ethnographic studies on community beliefs about ARI in children, with particular emphasis on documentation of the terms, signs and symptoms by which families recognize the illness.

Effectiveness of control programs for pneumonia among children in China and Fiji.

This article summarizes the implementation and efficacy of the World Health Organization's standard case management program for pediatric pneumonia in three counties in China and in the Western Division of Fiji. The information provided through this program was simple enough to be understood by parents and health care workers with a basic educational background. The program reduced mortality from pneumonia even when implemented through the existing health care system in a relatively poor county in China. The factors important in the success of the program included improved recognition of the signs of childhood pneumonia by parents, earlier presentation of children with these signs to health care facilities, availability of antimicrobial agents at the primary health care level, and rational decisions by health care workers about the use of these agents.

Immigrant Families Coping with Schizophrenia Behavioural Family Intervention v. Case Management with a Low-Income Spanish-Speaking Population

This investigation compared the effectiveness and cross-cultural applicability of behavioural family management (BFM) and standard case management in preventing exacerbation of symptoms and relapse in schizophrenia. Forty low-income Spanish-speaking people with a diagnosis of schizophrenia were randomly assigned to receive standard case management or behavioural family management after stabilisation with neuroleptic medication. Survival analyses indicated that among the less acculturated patients BFM was significantly related to greater risk of exacerbation of symptoms. Among the more acculturated patients, risk of exacerbation could be predicted by medication compliance but not by type of intervention. In analyses of symptom severity and functional status at 1-year follow-up, the level of patient acculturation was found to be significantly related to various measures of treatment outcome. Sociocultural factors affect responses to different types of intervention. The results did not support earlier findings of a beneficial effect of BFM when applied to a socioculturally diverse population.

Evaluating use of continuous treatment teams for persons with mental illness and substance abuse

Continuous treatment teams serving persons with co-occurring severe mental disorders and substance abuse disorders at seven sites in New Hampshire were evaluated to determine their fidelity to a model based on the Program for Assertive Community Treatment. Continuous treatment teams and standard case management programs at the seven sites were evaluated on 13 criteria for fidelity to the continuous treatment team model over a 27-month period. Data sources included clinicians' activity logs, agencies' management information systems, interviews, observation of staff activity and practices, and clinical records and other documents. The continuous treatment teams scored significantly higher than the case management programs on ten of the 13 criteria. The teams were more effective than the case management programs in implementing substance abuse treatment. Evaluation of the programs' fidelity to the model criteria allowed differentiation of successfully implemented continuous treatment teams from standard case management and from an unsuccessfully implemented team. The results confirm the need for careful measurement of model implementation and for investigation of organizational issues such as administrative support and clarity of program mission.