Provided by David Satcher, M.D., Ph.D.
Surgeon General of the United States of America
Chapter 3: Children and Mental Health
Services Interventions
Treatment Interventions
Case Management
Case management is an important and widespread component of mental health
services, especially for children with serious emotional disturbances. The main
purpose of case management is to coordinate the provision of services for
individual children and their families who require services from multiple
service providers. Case managers take on roles ranging from brokers of services
to providers of clinical services. There is a considerable amount of variation
in models of case management. In one important model, called “wraparound,” case
managers involve families in a participatory process of developing an
individualized plan focusing on individual and family strengths in multiple life
domains. Research on wraparound is still in its early stages (Burns & Goldman,
1999).
There have been controlled studies of three programs that used case managers who
work individually rather than as part of an interdisciplinary team (discussed
later). In one study of the Partner’s Project in Oregon, case management was
compared with “usual services,” which did not include case management (Gratton
et al., 1995). The authors found at 1-year followup that children in the
Partner’s Project scored significantly higher on measures of social competence
and had received more individualized, comprehensive services, and a greater
degree of service coordination.
The second study compared the outcomes of intensive case management and regular
case management for mentally ill homeless children in Seattle (Cauce et al.,
1994). The case managers in the intensive condition had lower caseloads, were
required to spend more hours supervising the youth, had flexible funds (for
clothing, transportation, etc.) at their disposal, spent more hours in
consultation with psychologists, and were of higher educational status. After 1
year, the study found that both groups showed substantial yet similar
improvement in mental health and social adjustment.
A model known as Children and Youth Intensive Case Management (CYICM) was
evaluated in two controlled studies. The program has been described as an
Expanded Broker Model, which means that the case manager, in addition to
brokering services, is responsible for assessment, planning, linking, and
advocating on behalf of the youth and family. Case managers, with caseloads of
10 children, are given $2,000 of flexible funds per child each year to purchase
treatment and ancillary services (e.g., transportation and educational aids). In
the first study, the authors found that children in the program spent
significantly more days in the community between episodes of psychiatric
hospitalization and were hospitalized for fewer days than before enrollment
(Evans et al., 1994). A subsequent study evaluated a random sample of 199
children enrolled in CYICM (Evans et al., 1996b). Findings at 3-year followup
indicated significant behavioral improvements and decreases in unmet medical,
recreational, and educational needs compared with findings at enrollment. As in
the previous study, children who had been in CYICM for 2 years had spent fewer
days in psychiatric hospitals and more days in community settings during the
intervals between hospitalizations. This study went further to compare their
hospital utilization with that by children not enrolled in the program. Although
CYICM clients spent more days in psychiatric hospitals before enrollment, they
used inpatient services after enrollment significantly less than did
non-enrollees. CYICM clients’ hospital admissions declined fivefold after
enrollment whereas among non-enrollees the decline in admission rates was less
than half that value. This difference translated into a savings of almost
$8,000,000 for New York State, where the project took place.
Some research has investigated the effects of extending case management on
children with a dual diagnosis of a mental disorder and a substance abuse
problem. Within the CYICM program, researchers looked at whether adolescents
with mental disorders and substance abuse problems derived comparable benefits
from the program as did those without substance abuse problems (Evans et al.,
1992). No significant differences were found in the average number of inpatient
admissions both before and after enrollment. There was also no significant
difference between groups in the average decrease from pre- to postenrollment in
the number of days spent in hospitals. These results indicate that case
management can be as effective for youth presenting with substance abuse
problems as for youth presenting with other psychiatric disorders.
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