Critical Path Network

Case managers help mentally ill avoid hospitalization, remain in the community

Program targets both adults and children

An intensive case management program at Community Hospital in Chester, PA, helps children and adults with serious mental illnesses manage their conditions, avoid hospitalizations, and stay in the community.

Community Hospital is a division of Crozer-Chester Medical Center, a 422-bed tertiary care hospital about five minutes away in Upland. Both hospitals are part of the Crozer-Keystone Health System.

The program, currently funded by the Common-wealth of Pennsylvania, was started in 1987, after a woman with a serious mental illness shot and killed six people at a shopping mall. The woman had made multiple visits to several psychiatric agencies but never stayed in treatment.

"That highlighted the fact that there are a lot of seriously mentally ill people in Delaware County who were not maintaining regular contact with a treatment program. The shooting was the impetus for outpatient mental health case management for adults. The children's program is an outgrowth of what happened with the adult program," says Colleen Healy, MA, MBA, director of child and family services for Crozer-Chester Medical Center.

The care of people in the program is coordinated by case managers who have a minimum of a bachelor's degree in the social services field. The case managers who work with the most seriously ill patients who need frequent contact are called intensive case managers (ICMs). Those who work with patients who are slightly less at risk and need fewer interventions are called resource coordinators (RCs).

The hospital is moving toward a blended model of case management, adapting the level of care to the patient's level of function to maintain continuity of care as the patients improve and need fewer interventions, reports Terri Venello, RN, director of adult and geriatric services at Crozer Chester Medical Center.

The hospital offers a full array of psychiatric and substance abuse treatment programs for all ages, from childhood to geriatric patients. A large percentage of the adults and children eligible for the ICM program are identified when they come in for a general psychiatric intake. The rest are referred by other providers, schools, inpatient hospitals, residential settings such as group homes, and other support services in the community.

Initially, the program was a maintenance program, aimed at keeping patients in the community. Recently the case managers have taken a more proactive approach to help patients recover from psychological illnesses. Recovery principles are being used to assist clients in developing plans to guide this process.

The intensive case management program is a 24-hour-a-day program. On weekends, one case manager is on call to assist people by meeting them in the crisis department if they need to be evaluated.

Almost all the adult clients in the case management program have diagnoses of serious mental illnesses, such as schizophrenia, major mood disorders, or depression. Some are substance abusers. Many have co-occurring disorders with substance abuse and mental health issues. A small subset has just come out of the prison system.

"With children, we're not dealing so much with chronic and serious mental illnesses. For many children, what we are trying to do is reduce their chance of being placed out of the home if they have a behavioral health issue," Healy says.

Children who qualify for the program are involved in a multiple child-serving systems, including mental health, special education, child welfare services, juvenile justice, drug and alcohol treatment, or mental retardation services. If a child is in two or three child-serving systems, he or she is evaluated for the program.

Eligible adults have had lengthy hospitalizations for mental illness, multiple face-to-face encounters with emergency service personnel, spent three or more years in a community mental health program, or have demonstrated an inability to comply with a medication regimen.

Caseloads

Intensive case managers carry a caseload of 18 children or 18-24 adults. Resource coordinators have a caseload of 22 children or 30-50 adults.

When a case manager gets a referral for a child in the program, he or she calls the family or the individual and arranges for a home visit within two weeks after the case is opened. He or she conducts a strengths-and-needs assessment of the child and the family and develops a service plan.

"The case manager and family work on what their goals are involving school, mental health treatment, and child welfare when needed. The plan gives us structure and focus," Healy says.

Many adult clients have been ill for so long that they have little family support or they don't want their families involved. In these cases, the case manager assists the client in developing a support network. All clients are assessed and participate in the development of a service plan that sets the framework for working with the patient.

Clients in the program fill out a self-assessment scale every six months, indicating areas where they feel they have improved and those where they still need help. The case managers use them to make any modifications to the service plan.

The ICMs and RCs are expected to spend 75% of their time in the community, going to homes, schools, courts, welfare offices, and anywhere else they can find their clients.

They make regular home visits to all clients and school visits with children in the program. If a child has a court appearance, whether it's for juvenile justice or child welfare, the case manager accompanies him or her and usually provides the transportation.

The case managers often accompany clients to clinic visits or to access community resources.

"The case managers pick them up and take them to appointments and do whatever it takes to help patients develop a more normal lifestyle and stay in the community," Venello says.

The case managers don't drive the clients to their appointments as a convenience to the clients. They do it to ensure that the client will show up for the appointment, she adds.

"We accompany them because they need to access service and there is a likelihood they wouldn't get there on their own," Venello says.

There is a 50% no-show rate at the hospital's mental health clinics, she says.

"These families often are disorganized and overwhelmed by all that is going on in their lives. The parents often have drug and alcohol problems. Without that intensive case manager or resource coordinator being there to give them structure, a lot of kids and families wouldn't make it," Healy says.

The case managers develop a close relationship with the clients and their family members.

"The program has been so successful because the clients and family members know that the ICM or RC is their advocate and has their best interest in mind. The relationship they develop is remarkably strong and trusting," Healy says.

Some people have been in the program since it started in 1987. "Case management is a very big part of these clients' lives, particularly those with no family or community resources. The people in the program are more compliant with their psychiatric treatment plan, take their medications, and go to their appointments. Having someone to guide them has made a big difference in their lives," Venello says.

When the program was begun, statistics showed that the intensive case management reduced inpatient stays and crisis intervention for the patients. After a few years, the state of Pennsylvania was so convinced of the value of the program it no longer required outcomes documentation.

"At first, we tracked the outcomes very closely; but within a couple of years, it became so clear that the program was doing what it was intended to that it was no longer required by the state that we report the statistics," Healy says.

(Editor's note: For more information, contact Terri Venello, RN, at e-mail: terri.venello@crozer.org, or Colleen Healy, MA, MBA, at e-mail: colleen.healy@crozer.org.)