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Step-by Step: A Comprehensive Approach to Case Management
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What is case management? How do you choose the right approach for your organization? What supports do case managers need to provide quality case management services? This article offers the answers to these questions and more.

Case management is one of the primary services offered to individuals and families who face multiple challenges, including severe mental illness, addiction, and homelessness. Many organizations offer “case management” without clearly defining what this means, why they chose a particular approach, how it relates to existing case management models and outcomes, and how they prepare case managers to provide these services. The following are steps organizations can take to begin to design a comprehensive approach to case management.

Step One: Research your options

Organizations with a working knowledge of case management models and associated outcomes can make informed decisions about which model or models may work best for their agency and population. Consider the following common case management models with an eye for what you currently do or approaches you would like to incorporate:

Standard Community Care Models

Broker Case Management Model

First formally articulated approach to case management. Focus on assessing needs, referring to services and coordinating and monitoring on-going treatment. Case manager coordinates services provided by a variety of agencies and professionals. Services are mainly office-based.

Clinical Case Management Model

Emerged out of a need for case managers to provide some therapeutic services. Many functions are similar to the Broker Model, including engagement, assessment and planning, and community linking, but with the added component of therapeutic interventions such as psychotherapy, psychoeducation and crisis intervention. Work is mainly office-based. Case managers are clinicians.

Intensive Comprehensive Care Models

Assertive Community Treatment (ACT)

Originally created by Stein and Test, the Program for Assertive Community Treatment (PACT) was designed as a community-based alternative to the hospital for those with severe mental illness. The ACT model is an intensive and comprehensive approach to case management. Approach is defined by smaller case loads (10:1); a multi-disciplinary team approach (usually at least two case managers, a nurse, and a psychiatrist); shared case loads; services delivered by the team in person’s natural environment vs. making referrals outside of the team; unlimited timeframe; 24 hour coverage. A range of services are provided (e.g., mental health, housing, daily living skills, socialization, employment, crisis intervention, substance abuse treatment).

Intensive Case Management

Developed to meet the needs of high service users and defined by low staff to client ratio, outreach, services brought to the client, practical assistance in a variety of areas. The main distinction from the ACT model is that caseloads are not shared.

Critical Time Intervention (CTI)

Specialized, time-limited intervention for the transition from institutional to community care for people experiencing homelessness and mental illness. Designed to bridge the gap between homeless specific services and community services. Phase-oriented approach to case management with a focus on building community support networks and facilitating a gradual transition to community-based service providers over a period of 9 months.

Rehabilitation-Oriented Community Care Models

Strengths Model

Developed in response to concerns that other case management models focused mainly on limitations and impairments vs. strengths and capabilities. Focus on strengths vs. pathology, the helping relationship as essential, contact in the community, and a focus on growth, change and consumer choice. Case managers provide direct services.

Rehabilitation Model

Emphasizes the importance of consumer-driven goals and assessing and building concrete skills to attain these goals.

Source: Mueser, Bond, Drake, & Resnick, 1998; Herman, Conover, Felix, Nakagawa, & Mills, 2007.

An organization may choose one model to adopt with fidelity or they may use a combination of strategies. It is important to include program staff in the process of selecting or adapting a case management model. One way a program can do this is by creating a multi-disciplinary workgroup consisting of a core group of staff representing all roles in the agency. Once an organization finalizes its approach to case management, all staff should receive a summary of the key components of the model.

Step Two: Make professional development a priority

A comprehensive approach to case management includes developing clear expectations about the core skills and competencies necessary to provide quality case management services. Using common performance standards allows for consistent expectations across an organization. Organizations may consider researching and identifying core competencies and practices on which to base their trainings, professional development strategies, and performance evaluations (see below).

The Community Support Skills Standards

The Community Support Skill Standards were developed in 1996 by the Human Services Research Institute in Cambridge, Massachusetts, and represent a national set of competencies for direct support professionals, including advocates, case managers, housing specialists, outreach workers, and vocational counselors. These Skill Standards have been approved by the National Alliance for Direct Support Professionals, and they inform the College of Direct Support, an Internet-based curriculum for direct support professionals.

Step 3: Evaluating the Impact of Your Services

Organizations must evaluate the effectiveness of their case management approach and make adjustments as needed. Organizations may begin this process by considering the following strategies:

  1. Be clear what you want to learn.
  2. What outcomes are you expecting for staff and consumers (e.g., decreased hospitalizations, increased staff retention, maintained housing)? What do funders want to know? Are there specific aspects of your model that would you like to focus on?

  3. Gather information.
  4. Develop concrete strategies for collecting information about the questions you are trying to answer. Specific methods of data collection should be formally integrated into your service design. Quantitative data may be collected through methods such as surveys, record reviews, and analysis of existing program data. Qualitative information can be collected through focus groups and interviews with consumers and staff, observations, and case studies.

  5. Analyze data.
  6. Create a plan for collecting, consolidating, and reviewing information about service activities. Look for themes and patterns and refer back to original questions and anticipated outcomes.

  7. Use the data.
  8. Develop systems for providing feedback or reports based on what you find. Adjust service design and delivery where appropriate based on outcomes.

Conclusion

Providing quality case management requires organizations to prioritize effective service design and delivery. To do this, it is important to be proactive and strategic when choosing a case management model, make professional development a priority, and identify methods for documenting and evaluating your case management services. With a clearly articulated and well-evaluated case management model, organizations can better serve individuals and families and set the stage for future growth and development.

For Further Reading:

Herman, D., Conover, S., Felix, A., Nakagawa, A., & Mills, D. (2007). Critical time intervention: An empirically supported model for preventing homelessness in high risk groups. Journal of Primary Prevention, 28, 295-312.

Mueser, K.T., Bond, G.R., Drake, R.E., & Resnick, S.G. (1998). Models of community care for severe mental illness: A review of research on case management. Schizophrenia Bulletin, 24(1), 37-74.

National Alliance for Direct Support Professionals. (2008). The 15 NADSP Competency Areas. Minneapolis, MN: Author.

Nelson, G., Aubry, T., & Lafrance, A. (2007). A review of the literature on the effectiveness of housing and support, assertive community treatment, and intensive case management interventions for persons with mental illness who have been homeless. American Journal of Orthopsychiatry, 77(3), 350-361.

Rapp, C.A., & Goscha, R.J. (2006). The principles of effective case management of mental health services. In Davidson, L., Harding, C. & Spaniol, L. (Eds.), Recovery from Severe Mental Ilnesses: Research Evidence and Implications for Practice (pp. 24-51). Boston, MA: Center for Psychiatric Rehabilitation.

Rubin, A. (1992). Is case management effective for people with serious mental illness? A research review. Health & Social Work, 17(2), 138 – 150.

Taylor, M., Bradley, V., & Warren, R. Jr. (1996). The Community Support Skill Standards: Tools for Managing Change and Achieving Outcomes. Skill Standards for Direct Service Workers in the Human Services. Human Services Research Institute. Cambridge, MA.

Ziguras, S.J., & Stuart, G.W. (2000). A meta-analysis of the effectiveness of mental health case management over 20 years. Psychiatric Services, 51(11), 1410-1421.

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