Community Care and Case Management in Mental Health Care Services in Australia.

INTRODUCTION:

Over that past two decades the psychiatric services and mental health care support has shifted to community from hospitals (McGorry, Bates, & Birchwood, 2013). Managed care, patient centered care models and case management reinforces this trend. Mental illness, mental health importance is better understood, and less stigmatized, and mental healthcare services are more familiar and commonly used (Andrade et al., 2014). Despite of available treatment options, community care support and rehabilitation programs, patients with mental illness may not receive required treatment and care when needed, consistent with evidence-based standards (Clement et al., 2015). Today challenges are bigger for individuals with mental illness and patients with persistent and serious mental health conditions who rely on generic health and welfare programs and integrated services for mental health (Mechanic, 2007). Failure in community care and health services provision may cause recurrent need of hospitalization, readmissions and recurrence of treatment phases and it may lead to increased social issues, diversion to jail and arrest and other community problems (Clement et al., 2015).

Despite progress, implementation of patient-centered community care services and effective mental health care system remains a formidable challenge. In this essay, a literature analysis of current mental health care services legislations, current community care models and case management strategies has been conducted. Based upon the findings we will describe different community care models for mental illness, the best practicing community care model and to elaborate mental illness’ importance and mental health care we will focus our studies on Australian mental health statistics and its health care provision in relation to community care models state-wide and nationally.

BACKGROUND

Most of the people with a history of mental illness have a complex array of personal and social needs that need to be considered. Case management is one of the most operational and among major types of community aftercare that provides ongoing management of chronic illness or recurring health issues (Sanborn, 2014). Generally, this population experiences a “revolving door”, a recurring pattern of hospitalization, discharge and readmission because of inadequate community support and unattended treatment support. The more intense is the experiences of mental illness and chronic illness, the more need of case management approach is required for people with mental illness and for their families and carers (Mechanic, 2007).

There are various models for case management (Miller et al., 2013), but the major case management models that are supported by literature and evidence based studies are Assertive Community Treatment (ACT) and Intensive Case Management (ICM) (Hanlon, Wondimagegn, & Alem, 2010). Each model has its specific role, strengths and purpose and for the effective implementation of any model, it is important to keep the specificity and purposes of these models in consideration (Miller et al., 2013). Before explaining the context of both case management models and their current role of participation in Australian Mental Healthcare System (AMHS), a historical background of the initial concepts and ideas of bringing these models in community level care is important for effective understanding (Sanborn, 2014).

 The deinstitutionalization movement which started in 1950’s and 1960’s and massive deinstitutionalization in the 1970s and 1980s shifted the focus of treatment for most patients with mental illness and psychiatric disorders from the conventional hospital services to the community care (Kakuma et al., 2011) . This movement made major changes in mental health laws and implications, making coercive treatment less possible. Although the hospital treatment included reasonable antipsychotic and antidepressant therapies but after hospital services, the patients were allowed to access the alcohol and street drugs, resulting in substantial increase in substance abuse comorbidities (Rapp & Goscha, 2006). These patients posed major imbalance in treatment and management problems that caused increased imprisonment and captivity (Smith & Newton, 2007).

Proposal and implicit of Act 1963 for Community Mental Health Center (CMHC) pave the way for the development of local mental healthcare centers, proposing the concept of providing healthcare support to the patients in centrally located mental healthcare facilities with similar hospital treatments and a prime difference of keeping the patients a part of community living instead of hospitalized treatments (Goldberg & Huxley, 2012) . As CMHCs started its operational activities and began providing services to mentally ill patients, the development of additional health services for this population on community level turned out to have both positive and negative effects. Some services became available even for people with less severe illness, on the other hand the complexity and multiplicity of new mental healthcare services made it difficult for patients with severe mental illnesses to access necessary services (Rapp & Goscha, 2006). Instead of easy access to community services, CMHCs proved to be more complex for the patients who would have been treated in hospitals formerly (Hackman & Stowell, 2009).

In response to the demands and growing need for community based and patient centered healthcare services, the National Institute of Mental Health established the Community Support Program (CSP)(Smith & Newton, 2007). Recognition of the need to provide healthcare support and services for patients with severe mental illness and to coordinate additional psychiatric services led to the development of a new healthcare design and service function, case management, and ultimately a new mental healthcare professional, the case manager (Hackman & Stowell, 2009). With the evolving trends of care in mental healthcare system, the scope of case managers has become more broad and various new models for case management in mental health care services have evolved, in which few of the models go beyond the scope of case management including direct clinical services of rehabilitative and social services (Goldberg & Huxley, 2012).

Different case management models in mental healthcare services have been developed including the clinical case management model, the broker service model, the assertive community treatment model, the intensive case management model, the rehabilitation model and the strengths model (Ziguras & Stuart, 2000). All models were developed by the demand and needs of a particular era and limitation of one model gave evolvement of another model which could be implemented more effectively (Rosen & Teesson, 2001). The broker or expanded-broker model had five case management principles, including assessment, planning, linking to services, monitoring and, advocacy. But a limitation in this model which made case managers not to participate themselves in the case management as clinicians made it problematic assuming the fact that clinical skills are needs to perform and efficient role in case management (Kirmayer, Guzder, & Rousseau, 2013).

The clinical case management model was developed on recognized facts that case managers need to participate as clinicians for effective case management, yet this model put limitations and a complex understanding that case managers are clinicians with psychotherapy psychoeducation specialty (Burns, 2010). The Program for Assertive Community Treatment (PACT) was programmed and designed with specialized care services for patients diagnosed with severe mental illness or psychiatric impairments (Nordentoft, Rasmussen, Melau, Hjorthøj, & Thorup, 2014). Commonly referred as ACT, assertive community treatment model or assertive continuous care teams, was developed to serve as a comprehensive treatment package to patients with severe mental illness and went beyond the confines and limitations of past case management models (Bond & Drake, 2015). Mental healthcare services delivered by ACT model are multidisciplinary services focusing on low patient to staff ratio, services provided in community instead of hospitals, shared caseloads between case managers and clinicians, constant coverage, direct services by ACT team, and time unlimited services (Nordén, Eriksson, Kjellgren, & Norlander, 2012). The unique services offered by this model and evidence based controlled study on ACT model led a large body of research to the adoption and implementation of this model (Burns, 2010).

Development of Intensive Case Management Model (ICM) was a high services reform in the ACT model, as it was designed to avoid unnecessary services and costly treatments for patients with severe mental illnesses. The most prominent distinction in ACT and ICM is that caseloads are not shared in ICM model of practice (Dieterich et al., 2017). The strengths model is another influential model that was developed on case management approaches and concerns. And for better integration and community facilitation based program that provides community support to the mentally ill patients (Petersen, Lund, & Stein, 2011), focusing on patients’ strengths rather than pathological conditions and making case managers relation essential and primary in every case. An important component od strength’s model is to intervene the patient based on self determination and allowing the patient to learn, grow, and change without limiting themselves because of their serious illnesses (Rapp & Goscha, 2011). Similar to strengths model, a final model of case management was proposed, the rehabilitation model. Rehabilitation model focuses on patients’ personal achievements and goals rather than goals defined by mental health system, and letting the patients attain their personal goals and contribute to community (Fleming, Del Valle, Kim, & Leahy, 2013).

DISCUSSION

The statistical analysis of mental health issues and illness in Australia according to Australian National Bureau report shows that a high percentage of Australian population suffers through mental illness each year. Among this population the young population aged 12-25 years have high incidence and prevalence of mental illness and health issues across the life span and a disproportionate diseases burden which is associated with mental disorders is due to inaccessibility to available health care services and mental support services. A major factor for this poor performance in the provision of healthcare services for mental illness is the design and pattern of our mental healthcare system. The current design of our mental healthcare system is manifestly inadequate for the complex and unique requirements, and cultural needs of people with mental illness.

Different case models that have been discussed above are mainly developed for a common goal which is helping the survival of patients’ with mental illnesses and optimizing their adjustment in the community. Most researched have been conducted on assertive community treatment (ACT) (Bond & Drake, 2015) and Intensive Case Management (ICM) models (Tsemberis, 2011). Controlled studies on these models indicate that these models provide better optimization of mental health care services by reducing the hospital stay, frequency of hospitalization, and better housing stability. ACT and ICM have moderate effects on stable and better life quality and improving symptomatology (Dieterich et al., 2017). Studies have shown that patients withdraw for ACT or ICM services may result in deterioration of health and limited gains. Utilization of ACT or ICM models in healthcare services have proven to have effects on social functioning, vocational functioning and ratio of arrests.

A number of factors are responsible for the effects of community care on cost effectiveness across different models of case management and settings. Most studies of cost-effectiveness of community care models and case management have focused on ACT model, with many indicating net savings and better outcomes (McCrone, Craig, Power, & Garety, 2010). There is a consensus that case management models like ACT are most effective for patients who have a history of high services use, since ACT model based services relocate the expensive treatments and hospitals services to less costly, community based services (Monroe-DeVita, Teague, & Moser, 2011).

There have been substantial advances in community care model and case management, evaluating the different aspects to community care but there is ambiguity and limited understanding of the factors that are responsible for successful and unsuccessful applications and implementations of these models. Research and further studies for the evaluation of the fidelity of these models to determine different determinants of positive and negative outcomes by using these models is suggested. Research on other models of case management is inconclusive and directions for future research on community care models, evaluation of implementation and predictors of improvement are suggested Methods for measuring case managers’ activities in different case models have been developed but few studies comparing different community care models have employed these measures (Corrigan, Mueser, Bond, Drake, & Solomon, 2012). It is becoming evident that no single community care model is equally appropriate across all clinical settings, thus research is needed to determine geographical impacts and to determine performance of models in relation to geography.

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