Case management programs attempt to reduce the use of psychiatric hospitalization for clients with long-term mental illness, inpatient treatment still is required for many individuals in even the best community support systems.
Even when formal mechanisms for hospital-community liaison exist, there often is little effective collaboration between hospital and community treatment staffs. Depleted from struggling with relapsing patients, case managers often discontinue their efforts during hospitalization. At the same time, hospital staff often demonstrate little interest in community caregivers until discharge planning begins in earnest. Hospital staff and case managers have common barriers to effective collaboration, but they can work together toward the goal of achieving maximum benefit from hospitalization within the context of a long-term community plan.
As community programs for clients with long-term mental illness have expanded in the past decade, case management has become the central intervention strategy for practicing social workers. Along with maintenance on psychotropic medications, case management is one of the primary therapeutic approaches for reducing recidivism and implementing a social policy of deinstitutionalization. However, although repeated studies have demonstrated that case management can have a major impact on recidivism rates (Bond, Miller, Krumweid, & Ward, 1988; Goering, Wasylenki, Farkas, & Ballantyne, 1988; Stein & Test, 1980), even the most intensive programs cannot eliminate the intermittent necessity of psychiatric hospitalization.
There is often confusion about models of case management (Johnson & Rubin, 1983). In this research I refer to the "clinical case management" model, which integrates clinical understanding with environmental intervention in the context of an empathic. Supportive relationship with clients and their families (Harris & Bachrach, 1988; Kanter, 1985, 1987, 1989, 1990). In this model, the case manager delivers a wide range of services — including family consultation, intermittent individual psychotherapy, collaboration with physicians and hospitals, crisis intervention, and social network maintenance beyond the brokerage functions of assessment, planning, and linking. Social workers should find this holistic intervention model compatible with the traditional descriptions of social casework. Recognizing that case management currently is being delivered by a combination of social workers, other mental health professionals, and paraprofessionals. There are a range of case managers who identify with the clinical case management model.
Although the conventional wisdom suggests that psychiatric patients were rarely returned to the community before the introduction of neuroleptic medications, social workers were actively involved in the interface between hospital and community since the early years of the 20th century (Lay, 1955). There was little community programming in the years before World War II, but hospital social workers experimented with foster care placements and provided family support for a small but steady stream of discharged patients. Lacking a network of community facilities, many of these hospital social workers continued to serve their patients in an aftercare capacity (French, 1940).
When community care was provided by the aftercare departments of psychiatric hospitals, continuity of care for discharged patients in the vicinity could be provided effectively by hospital staff (Barton, 1955; Chittuck, Brooks, Irons. & Deane, 1961). However, as the locus of treatment shifted to community programs administratively separated from hospitals, more conscious efforts at collaboration were necessary. Although economic pressures to reduce hospital censuses have a major impact on the discharge planning process, social work values mandate that the needs of individual clients for recovery, security, and community stabilization not be sacrificed for economic or policy concerns. Excessive use of hospitalization is both harmful to many clients and a misuse of a costly social resource, but there are sometimes occasions, as illustrated by the following vignette, where advocating for extended inpatient treatment becomes an important element in effective case management.
Effective liaison programs do not preclude the necessity for direct communication between the client's case manager and hospital staff and even, as suggested by Ms. Miller's case, direct contact between the case manager and the client. As Altman (1982) reported, even a single face-to-face conference between clients, hospital social workers, case managers, and other community caregivers can have a remarkable impact on aftercare compliance, reducing post-hospitalization recidivism from 64 to 22 percent.
In contrast, hospital staff often view case managers as naive and unprofessional. These perceptions may be accurate in some communities that devalue the clinical skills needed in case management and employ poorly trained case managers (Kanter, 1987), but these views sometimes reflect professional prejudices. Hospital staff may use these prejudices as an excuse not to reach out to community caregivers and impart valuable information when clinical backgrounds are deficient. Although some inpatient stall may wish to return to an era when hospital care was the primary treatment modality, distancing themselves from case managers will neither reverse social policy nor serve their patients after discharge.
In addition, both case managers and hospital staff experience countertransference reactions around their clients' relapses that are acted out during hospitalization. Frequently, re-hospitalization follows a lengthy process of decompensation, which leaves case managers feeling angry, helpless, and guilty. A common strategy for coping with this emotional burnout is to withdraw from the client and use the hospitalization as a respite from involvement. Although case managers consciously may express considerable dedication to their clients, they often unconsciously harbor a wish to abandon them (Kanter, 1988).
On some level, case managers also may experience relapse as a personal failure and withdraw out of an unconscious sense of shame. Rather than confront these sentiments, case managers often justify disengagement during hospitalization as a response to systems issues or professional conflicts.
Case Study Example:
Mr. Norton, a 28-year-old single man diagnosed with schizophrenia, paranoid type, had confined himself to a room in the family home for nearly three years. After four months of outreach in his home by the case manager. He was committed involuntarily to a state hospital. Compliant and superficially cooperative, he was released one month later and referred for day treatment and medications. Six weeks after discharge, he discontinued his medications and attendance at day treatment. Several months of outreach proved unsuccessful, and Mr. Norton was re-hospitalized.
Aware of the previous difficulties after discharge, the case manager worked closely with Mr. Norton's parents to establish conditions for his return home, including allowing them to administer his medication and arranging for him to participate in a day activity. Although Mr. Norton's psychosis had largely remitted after one month, he would not agree to cooperate with his parents. Over the next eight months, the case manager visited the hospital four times, conferring twice with Mr. Norton and his social worker and participating in one family meeting. The social worker offered Mr. Norton the option of referral to other housing programs, but he preferred not to live with such "sick" people.
In individual therapy and group therapy, the hospital consistently addressed Mr. Norton's refusal to accede to his parents' expectations, and he finally agreed to their terms for returning home. After consultation with both Mr. Norton and his family, the hospital started injectable medication shortly before discharge. This time around, the aftercare plan proved successful and Mr. Norton has cooperated with treatment for more than 18 months following discharge, attended his day program regularly for the first year, worked at a part-time job, and took classes at a community college.
While responding to the overtures of the case manager, hospital staff also can take a proactive role in contacting and engaging the case manager and other community caregivers. Recognizing the aforementioned countertransference reactions precipitated by client relapse, hospital social workers can express an interest in the case manager's perspective and offer to keep him or her apprised of the client's progress in the hospital. Again, establishing this relationship early in the course of hospitalization facilitates effective collaboration when more difficult issues regarding discharge planning must be confronted.
As Altman (1982) discussed, convening a discharge planning conference with the client, the family, the case manager, therapists, and other community caregivers is an excellent way of promoting compliance with aftercare treatment and reducing future recidivism. However, it is unclear whether the conference itself or the underlying attitude of openness is the critical therapeutic ingredient. Certainly, all the telephone calls involved in arranging for such a conference create a climate that facilitates effective cooperation.
Changes on systems and professional levels can enhance collaboration between case management programs, patients and inpatient facilities, but this cooperation ultimately depends on the personal efforts of the involved staff. Case managers and hospital social workers must recognize the implicit stresses in each other's roles most often, case managers are struggling to maintain large caseloads of very disturbed clients without the support and structure available in hospitals. Hospital social workers often are working within a stressful hierarchical milieu and are expected to develop discharge placements when resources are inadequate. With many clients, both case managers and hospital social workers are expected to accomplish the impossible and stabilize treatment-resistant clients with grossly deficient resources. In these situations, an open acknowledgment of their mutual frustration and helplessness can help case managers and hospital staff avoid the projection of blame that has soured so many efforts at collaboration. Hospital social workers are often as powerless to prevent premature discharge as case managers are to prevent re-hospitalization. In a climate of empathic collaboration, case managers and hospital staff can maximize their creativity in developing imaginative solutions to some of the most difficult problems in social work and case management practice.
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