Critique of Case Management Models
A plethora of case management models have been reported in this review. These different models were developed to meet unique client needs, health environments and workplace cultures (National Primary Care Research and Development Centre, 2005, 2006; Solomon, 2000). Case management is reported to be most successful when it provides for a flexible delivery style aimed primarily at meeting the unique needs of the target population (Dewing, 1997; Naleppa & Reid, 1998).
Case management models are categorised as either episodic (to address short-term plans), or continuous (for more long-term care strategies) (Carr, 2000). Episodic care involves a comprehensive integration of services to support the needs of a client for a short or defined period. While episodic care has a place in the health sector, there continues to be growing interest supporting a longer-term continuum of care model. Continuity in care enables fluidity of client progression from one service to another, while still maintaining and achieving individualised goals (Intagliata, 1982). Longer-term case management aims to meet the needs of chronically ill clients by minimising disease progression (Bailey, 1998; Carr, 2000; Coile & Matthews, 1999). The mode of delivery primarily depends on the target population, resource availability and the aim of the case management model.
The following outlines six case management models applied across the health care sector.
Assertive Community Treatment primarily services mental health clients. The model encompasses strict interventions such as operating seven days a week unlike most other models, responding to all crises, employing no more than 20% part-time staff, intensive face to face contact and 24 hour availability, ensuring team autonomy, and establishing inter-professional teams of at least three health professionals (including Social Worker, Occupational Therapist, Nurse and Medical Practitioner) plus a part-time psychiatrist (Deci, et al., 1995; Dixon, 2000; Simpson, et al., 2003; Tyrer, 2000). Rigorous research has demonstrated positive outcomes for this model. The Model has been met with much scepticism about the possibility of application and outcomes due to its bold implementation initiatives and high standards.
Assertive Community Treatment in general has been considered to be beneficial to the ‘system’ and clients alike, but it is noted that of the studies reporting positive outcomes, three were reviews (systematic review (Marshall, et al., 1998), meta-analysis (Ziguras & Stuart, 2000) and an integrative review (Rubin, 1992)), and the remaining two (Dincin, 1990; Marshall, et al., 1995) had lack of detail and risk of bias according to both NICE and GRADE criteria. Despite the low level of evidence supporting this Model it remains in wide use in mental health services. The restrictive implementation criteria and the expense involved does however limit its scope of use in many care settings; for example, the strict utilisation of no more than 20% part time staff would not be viable in the aged care sector. Key interventions of this Model relevant to aged care include increased client contact, availability to clients and inter-professional collaboration.
The Brokerage Model uses non-caregiver personnel as Case Managers, and therefore differs from other models. The Case Manager coordinates services implemented by other providers (Hangan, 2006; King, et al., 2004; UK700 Group, 1999). Browne and Braun (2001, p. 352) identified that the model provided significant support to family and clients alike and without it, the carers felt “less able to cope”. Nevertheless, the model has attracted criticism due to its non-direct and impersonal approach to case management, with limited value unless there are a defined set of goals appropriate for the client and family (Arnold, 1987; Burns, 1997; Kanter, 1991; Mueser, et al., 1998; Simpson, et al., 2003). The Brokerage Model provides a Model that is cost efficient (Andrews & Teesson, 1994), yet is rarely the preferred model for older clients (Simpson, et al., 2003). While this Model has limited scope within the aged care sector, it has the potential for use when considering the need to increase the involvement of non-regulated staff in case management, who comprise much of the workforce in the aged care sector.
The Case Management Society of America Model has slowly transitioned across a number of countries, including Australia (Case Management Society of Australia, 2004). This model integrates strong policies and professional standards of practice (Aliotta, Aubert, & Kirby, 1998). In this Model, the Case Manager performs a range of functions including assessor, advocate, facilitator (coordinator of care) and monitor of outcomes. Pivotal partnerships exist between the community, the client and the healthcare team (Case Management Society of America, 2002; White, 2004; White, et al., 2005). Characteristic qualities include a maximum caseload of 15, an orientation program for the Case Manager and flexibility in service delivery (Tyrer, 2000). This Model is suitable for the Australian context and preferred by the Case Management Society of Australia, with the potential for certification aligned directly to the Model. The essence of this Model speaks to the need for collaboration as a primary foci, as well as elements of caseload, education and the role of the Case Manager providing key foundational aspects needed in a Model of care. It is reported to offer the most flexible structure to support development and implementation across the sector, although only one research study confirmed this aim (White et al. ( 2005) (see Table 3.4).
Clinical Case Management that has been traditionally implemented in mental health environments is well regarded internationally (Chu, et al., 2000; Ziguras, Stuart, & Jackson, 2002). The model is characterised by individualised and flexible programs, community outreach, small caseloads, interagency coordination, strong therapeutic relationships between service providers and clients and continuity of care for clients with severe mental illness (Andrews & Teesson, 1994; Burns, 1996, 1997; Chu, et al., 2000; Kanter, 1989; Kanter, 1991; Lichtenberg, et al., 2008; Simpson, et al., 2003). Case Managers need to be professionally qualified with at least two years experience (Lichtenberg, et al., 2008). Clinical Case Management has generally proven effective and reported to decrease the cost of care and increase carer satisfaction, although sometimes linked to increased hospitalisation for mental health clients (Chu, et al., 2000; Ziguras, et al., 2002). This Model is suitable for the residential aged care sector and helps to develop interprofessional teams, given the focus on development of therapeutic relationships between client and carers.
The EverCare Model engages the skills and resources of a Nurse Practitioner in a risk-management approach, aimed at meeting the needs of old and frail community-dwelling (including residential aged care) clients (Carr, 2003; Kane & Huck, 2000; National Primary Care Research and Development Centre, 2005, 2006). The Model is described by Carr (2003) as focusing on enhanced communication through daily team rounds, inclusion of Nurse Practitioners in client management, improved coordination of services and facilitating client advocacy through comprehensive client assessments. Nurse Practitioners spend approximately one third of their time in direct client care, one quarter communicating with carers, staff and medical practitioners and the remaining time in administrative roles in this Model ( Abdallah, 2005; Kane, et al., 2001; Kane, et al., 2003). One study by Abdallah (2005) explored the role of the EverCare Nurse Practitioner and identified it as including; counselling, educator, clinician and communicator when working with residential aged care clients, however it was unable to substantiate their benefit to care practices or client outcomes. Despite this, some research on the USA Model reported it was effective in reducing hospital admissions and mortality (Elkan, et al., 2001), these outcomes were not reproduced in the UK which has facilitated a significant and extensive system review and culture of misgivings (Gravelle, et al., 2007).
Barriers to implementing the EverCare Model into Australia are many and include: small numbers of Nurse Practitioners (Gardner, Gardner, Middleton, & Della, 2009); lack of role clarity (Hader, 2010; Lash & Munroe, 2005); lack of policy and legislative challenges for scope of practice (Davidson, et al., 2006; Duchene, 2010); all of which are significant issues as these were present prior to the UK implementation (Gravelle, et al., 2007). Cultural shifts within the entire healthcare system in Australia need to be reviewed for Nurse Practitioners to take on this a role. Structural changes would need to include development of RNs’ education and skills in assessment, leadership and education, improved interprofessional collaboration, policy and legislation development and role clarity. These requirements have previously been identified in reviews of Australian aged care by the Productivity Commission (2010). However, the main issue with the requirement to employ Nurse Practitioners, or Nurse Specialists, to drive the Evercare Model is that the sector cannot afford to employ them, and certainly not the number of Nurse Practitioners/Specialists required.
Intensive Case Management has been implemented within mental health utilising interprofessional teams. There have been demonstrated improvements in clients’ quality of life and increased social engagement with the use of this model (Holloway & Carson, 1998; Marshall & Lockwood, 2000). Intensive Case Management has also improved client, carer and staff satisfaction (Hangan, 2006), increased engagement with service providers and reduced length of hospital stay for mental health clients (Marshall & Lockwood, 2000). This Model was found to be more successful where there was an active team of support staff (Holloway, Murray, & Squire, 1996), rather than a sole Case Manager (Hangan, 2006; Holloway & Carson, 1998; Nelson, Sadeler, & Cragg, 1995; Waite et al., 1997). Nevertheless, this Model has not always delivered clinical improvements with increased client contact (Andrews & Teesson, 1994; Burns, 2002; Castle, 2000; UK700 Group, 1999). As well, while there were some positive outcomes for clients with this resource-intensive model, there was also an increased burden on community services and a heavier workload for Case Managers (Bedell, et al., 2000). Intensive Case Management has provided key strategies that aim to improve client satisfaction and engagement in care, however success requires strategic and well considered implementation strategies for aged care.
Summary of Case Management Models reviewed
Following recommendations, a relevant Model of Care for use in the aged care sector should consider the inclusion of Case Managers, interprofessional collaboration, caseloads, pathways, case conferencing, accessibility and availability of Case Managers, and discharge planning. These case management elements have been further explored in the preceding description of a number of more widely accepted Case Management Models. Despite the lack of rigorous research in the Assertive Community Treatment Model and its specificity to mental health, dominant elements for consideration include ‘availability’ and ‘collaboration’. The Brokerage Model, again limited in design by relying on un-regulated staff acting in a predominantly administrative role, has been regarded as being very cost effective but not able to produce consistently positive patient outcomes. The Case Management Society of America Case Management Model has been validated by expert opinion yet lacks research to support its structure. However its recommendations for a low caseload, flexibility, collaborative approach and Case Manager development are important elements for inclusion in a Model of Care. Clinical Case Management has been supported by rigorous research, providing increased evidence for small caseloads, relationship-building, individual care planning, pathways, and a continuum of care design. The EverCare Model has been strongly supported for its focus on assessment, collaboration, client centred philosophy and skill required within the Case Manager role. Despite its stilted growth in the USA and UK, the EverCare Model has remained less than successful in achieving its aims. The key to this Model is the utilisation of Nurse Practitioners. However, the lack of policy and clarity of role, along with skill mix and cost of implementation would suggest it is both unmanageable and unsustainable. This is particularly the case in the current professional and political contexts for Nurse Practitioners in Australia. Intensive Case Management has also been well supported in the mental health sector, with demonstrated benefits in achieving collaborative partnerships, timely crisis management and providing evidence for reduced caseloads.
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