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
Team Approaches to Case Management
Several studies assessed the value of case management as part of a treatment
team. In a randomized trial in North Carolina (Burns et al., 1996), youth served
by an interdisciplinary treatment team led by a case manager were compared with
a control group of youth served by a treatment team led by their primary
clinician in the role of case manager (also called clinician case manager). At
1-year followup, case managers in the experimental group reported spending
significantly more time with their clients, as well as significantly more time
on the core functions of case management (e.g., outreach; assessment of
strengths, needs, and resources; service planning and monitoring; linking,
referral, and advocacy; and crisis intervention). The experimental group also
remained in the case-managed program longer, spent fewer days in psychiatric
hospitals, and received more community-based services and a more comprehensive
array of services. Although both groups showed similar clinical and functional
improvements, parents of youth in the experimental group reported more
satisfaction with the service system. The study concluded that traditional case
managers, rather than clinician case managers, provide a more cost-effective
method for attaining positive behavioral outcomes and access to mental health
services.
Another example of a team approach to case management is the Family Centered
Intensive Case Management (FCICM) program. This was originally created as a
variation of Child and Youth Intensive Case Management in New York, with the
later addition of a wraparound approach. The wraparound approach is based on a
belief that the child and family should be placed at the center of an array of
coordinated health and mental health, educational, and other social welfare
services and resources, which a case manager wraps around the patient and
family. In a randomized trial, children were assigned to either FCICM or
Family-Based Treatment (Evans et al., 1996a). Family-Based Treatment included
training, support, and respite care for foster families but did not include case
managers.
The findings at 18 months (or at discharge) indicated that children in FCICM had
significantly fewer behavioral symptoms and significantly greater improvements
in overall functioning than those in Family-Based Treatment. In addition, the
average annual cost of FCICM was less than half that of Family-Based Treatment.
The Fostering Individualized Assistance Program (FIAP) is an example of case
management provided through a wraparound approach. The effectiveness of this
model, which used clinical case managers, was compared with standard foster care
in a randomized trial involving 131 children and their families (Clark et al.,
1998). The most important duty of the FIAP case managers was to arrange monthly
team meetings for the monitoring of individualized service plans. Although both
groups showed significant improvement in their behavioral adjustment over a
3_-year period, children in the FIAP group were less likely to change
placements, and boys in the group reported better social adjustment and fewer
delinquencies. Older youth in the group were more likely to maintain placements
in homes of relatives and less likely to run away. Youth in FIAP were also
absent from school less often and spent fewer days suspended from school.
Overall, youth in the FIAP group showed more improvement than did youth in
standard foster care. Multiple uncontrolled studies of case management using a
wraparound approach were summarized in a recent monograph focusing on the
wraparound process (Burns & Goldman, 1999). Overall, the reviewed studies,
although using uncontrolled methods, offer emerging evidence of the potential
effectiveness of case management using a wraparound process.
While evidence is limited and many of the positive outcomes focus on service use
rather than clinical status, there is some indication that case management is an
effective intervention for youth with serious emotional disturbances. Studies in
this area are difficult to conduct because of resource limitations and of
varying approaches to case management. Agreement on standards for specific case
management models is
needed in order to proceed with efficient and reliable controlled research in
this area. In addition, future research needs to address the issue of
cost-effectiveness, as some evidence presented above has shown savings from less
utilization of institutional care.
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