Accounting for case manager effects in the evaluation of mental health services

Study protocol for a randomised controlled trial evaluating the effectiveness of strengths model case management (SMCM) with Chinese mental health service users in Hong Kong

INTRODUCTION

Strengths-based approaches mobilise individual and environmental resources that can facilitate the recovery of people with mental illness. Strengths model case management (SMCM), developed by Rapp and Goscha through collaborative efforts at the University of Kansas, offers a structured and innovative intervention. As evidence of the effectiveness of strengths-based interventions come from Western studies, which lacked rigorous research design or failed to assure fidelity to the model, we aim to fill these gaps and conduct a randomised controlled trial (RCT) to test the effectiveness of SMCM for individuals with mental illness in Hong Kong.

METHODS AND ANALYSIS

This will be an RCT of SMCM. Assuming a medium intervention effect (Cohen's d=0.60) with 30% missing data (including dropouts), 210 service users aged 18 years or above will be recruited from three community mental health centres. They will be randomly assigned to SMCM groups (intervention) or SMILE groups (control) in a 1:1 ratio. The SMCM groups will receive strengths model interventions from case workers, whereas the SMILE groups will receive generic care from case workers with an attention placebo. The case workers will all be embedded in the community centres and will be required to provide a session with service users in both groups at least once every fortnight. There will be two groups of case workers for the intervention and control groups, respectively. The effectiveness of the SMCM will be compared between the two groups of service users with outcomes at baseline, 6 and 12 months after recruitment. Functional outcomes will also be reported by case workers. Data on working alliances and goal attainment will be collected from individual case workers. Qualitative evaluation will be conducted to identify the therapeutic ingredients and conditions leading to positive outcomes. Trained outcome assessors will be blind to the group allocation.

ETHICS AND DISSEMINATION

Ethical approval from the Human Research Ethics Committee at the University of Hong Kong has been obtained (HRECNCF: EA1703078). The results will be disseminated to service users and their families via the media, to healthcare professionals via professional training and meetings and to researchers via conferences and publications.

TRIAL REGISTRATION NUMBER

12617001435370; Pre-results.

Battling in the trenches: case managers' ability to combat the effects of mental illness stigma on consumers' perceived quality of life

Intervention effectiveness research requires that investigators include "real world" variables in the design of studies to develop an understanding of how interventions perform in the "real world." Two areas that have been neglected in effectiveness research on mental health case management are mental illness self-stigma and the effects of different case managers. Self-stigma is a reality for many consumers that negatively impacts their lives. Case managers, themselves, are a potential source of autocorrelation and likely provide services differently. This study explores the relationship between self-stigma and quality of life for consumers receiving services from different case managers. Cross-sectional data were collected from 160 consumers of an urban case management agency. Self-stigma was negatively associated with quality of life. Case managers did not account for a significant amount of variance in quality of life scores. However, the interaction between case manager and self-stigma was significant. Some case managers were able to mitigate the negative effects of self-stigma on quality of life. Future effectiveness research in community mental health case management needs to account for the effects of self-stigma, case managers, and the interaction between the two in the research design.

The relationship between case manager expectations and outcomes of persons diagnosed with schizophrenia

The present study examined the relationship between case managers' expectations about the abilities of persons diagnosed with schizophrenia and the outcomes (as indicated via chart review) of a randomly selected sample of clients diagnosed with schizophrenia on their caseload. Results indicate that clients of case managers with higher expectations averaged significantly more months of progress in employment than clients of case managers with lower expectations. Case manager expectations were also better predictors of the number of days employed than other case manager and consumer characteristics, however the type of expectation was a critical determinant of the direction of the effect. Case manager expectations were not related to outcomes in living situation.

Development and validation of the RQC: a daily contact log for ACT and ICM teams

Aim– Instruments to measure the process - the daily activities of home care workers - have received little attention and may impede research in refining the active ingredients, the clientele best served and continuous quality improvement. We developed a decade ago in Quebec, Canada, a new daily contact log (relevé quotidien des contacts or RQC) that has now reached in practice 1 million entries.Methods– Three features distinguish the RQC development, namely, practical ergonomics, a clear logic, and response categories easy to understand and retain. The instrument is filled following any 10-minute or more contact with or about the client, and covers the location, time and actors of the episode of care, and the nature of the intervention (crisis, representing, accompanying, discussing) in 10 areas (i.e. medication, daily living activities, housing, relationships, substance abuse, legal, etc.). Inter-rater agreement for eachRQCresponse category and rater agreement with a criterion measure (coded vignettes) were evaluated.Results– Kappa coefficients and intra-class correlation coefficients yielded results ranging from at least moderate to generally substantial agreement for all 77 response categories.Conclusions– The newRQCmay support international studies of the implementation and application of various forms of intensive home care, refining its indications, and serves as a clinical and managerial tool to ensure quality of the interventions.Declaration of Interest:The study was financed by funds from the Fonds de la recherche en santé du Québec (FRSQ) and the Canadian Institutes of Health Research (CIHR). The authors have not been involved with any other forms of financing that might be considered a conflict of interest in connection with the submitted article.

Declaration of Interest:The study was financed by funds from the Fonds de la recherche en santé du Québec (FRSQ) and the Canadian Institutes of Health Research (CIHR). The authors have not been involved with any other forms of financing that might be considered a conflict of interest in connection with the submitted article.

Which factors predict case management services and how do these services relate to client outcomes?

The current study explores two issues: which factors predict case management services and which case management services predict outcomes. Thirty individuals with schizophrenia participated in the study. Information regarding clients' characteristics and the working alliance was collected within the first 2 months of participation in the program and again 1 year later. Case managers completed a daily contact log for each client over the course of the year. Results suggest that the working alliance is a strong predictor of case management services. The working alliance and the frequency with which housing and medication were discussed were strong predictors of community functioning outcomes. Directions for future research are provided that are based upon these preliminary findings.

The cost of residential addiction treatment in public housing

The cost of providing addiction treatment services in a variety of settings is useful information for program administrators, policy makers, and researchers. This study estimates the economic costs of providing substance abuse treatment services at Safeport, a three-phase residential treatment program focusing on addicted women living in public housing. Economic (opportunity) costs are estimated for each phase separately and for the complete program. Results indicate that the total cost of providing treatment services at Safeport in 2001 was $1,325,235. This total cost comprises $549,737 for stabilization or early abstinence (Phase I), $400,098 for relapse prevention and self-sufficiency (Phase II), and $375,400 for independent living preparation and long-term recovery (Phase III). Average daily census (number of clients/families on a typical day) was just over 11 clients/families in each phase or 34 clients/families for the entire program. The average length of stay in the three phases of the program was 12 weeks for Phase I, 20 weeks for Phase II, 18 weeks for Phase III, and 50 weeks overall. The average weekly cost per client amounted to $930 for Phase I, $677 for Phase II, $635 for Phase III, and $748 over the full program. The average cost per treatment episode amounted to $11,163 for Phase I, $13,541 for Phase II, $11,435 for Phase III, and $36,136 for the complete program. Future research should compare these cost estimates with corresponding outcome data from Safeport to perform a comprehensive economic evaluation.

The impact of routine outcome measurement on treatment processes in community mental health care: approach and methods of the MECCA study

Three issues characterise the background to the MECCA study: A) Throughout Europe, most patients with severe forms of psychotic disorders are cared for in the community. The challenge now is to make processes in community mental health care more effective. B) There are widespread calls to implement regular outcome measurement in routine settings. This, however, is more likely to happen, if it provides a direct benefit to clinicians and patients. C) Whilst user involvement is relatively easy to achieve on a political level, new mechanisms may have to be established to make the views of patients feed into individual treatment decisions. The MECCA study is a cluster randomised controlled trial following the same protocol in community mental health teams in six European countries. In the experimental group, patients' subjective quality of life, treatment satisfaction and wishes for different or additional help are assessed in key worker-patient meetings every two months and intended to inform the therapeutic dialogue and treatment decisions. The trial tests the hypothesis that the intervention--as compared to current best standard practice--will lead to a better outcome in terms of quality of life and other criteria in patients with psychotic disorders over a one year period. This more favourable outcome is assumed to be mediated through different treatment input based on more appropriate joint decisions or a more positive therapeutic relationship in line with a partnership model of care or both. Moreover, the study will hopefully reveal new insights into how therapeutic processes in community mental health care work and how they can be optimised.

A meta-analytic approach to growth curve analysis

A meta-analytic approach to growth curve analysis is described and illustrated by applying it to the evaluation of the Arizona Pilot Project, an experimental project for financing the treatment of the severely mentally ill. In this approach to longitudinal data analysis, each individual subject for which repeated measures are obtained is initially treated as a separate case study for analysis. This approach has at least two distinct advantages. First, it does not assume a balanced design (equal numbers of repeated observations) across all subjects; to accommodate a variable number of observations for each subject, individual growth curve parameters are differentially weighted by the number of repeated measures on which they are based. Second, it does not assume homogeneity of treatment effects (equal slopes) across all subjects. Individual differences in growth curve parameters representing potentially unequal developmental rates through time are explicitly modeled. A meta-analytic approach to growth curve analysis may be the optimal analytical strategy for longitudinal studies where either (1) a balanced design is not feasible or (2) an assumption of homogeneity of treatment effects across all individuals is theoretically indefensible. In our evaluation of the Arizona Pilot Project, individual growth curve parameters were obtained for each of the 13 rationally derived subscales of the New York Functional Assessment Survey, over time, by linear regression analysis. The slopes, intercepts, and residuals obtained for each individual were then subjected to meta-analytic causal modeling. Using factor analytic models and then general linear models for the latent constructs, the growth curve parameters of all individuals were systematically related to each other via common factors and predicted based on hypothesized exogenous causal factors. The same two highly correlated common factors were found for all three growth curve parameters analyzed, a general psychological factor and a general functional factor. The factor patterns were found to be nearly identical across the separate analyses of individual intercepts, slopes, and residuals. Direct effects on the unique factors of each subscale of the New York Functional Assessment Survey were tested for each growth curve parameter by including the common factors as hierarchically prior predictors in the structural model for each of the indicator variables, thus statistically controlling for any indirect effect produced on the indicator through the common factors. The exogenous predictors modeled were theoretically specified orthogonal contrasts for Method of Payment (comparing Arizona Pilot Project treatment or "capitation" to traditional or "fee-for-service" care as a control), Treatment Administration Site (comparing various locations within treatment or control groups), Pretreatment Assessment (comparing general functional level at intake as assigned by an Outside Assessment Team), and various interactions among these main effects. The intercepts, representing the initial status of individual subjects on both the two common factors and the 13 unique factors of the subscales of the New York Functional Assessment Survey, were found to vary significantly across many of the various different treatment conditions, treatment administration sites, and pretreatment functional levels. This indicated a severe threat to the validity of the originally intended design of the Arizona Pilot Project as a randomized experiment. When the systematic variations were statistically controlled by including intercepts as hierarchically prior predictors in the structural models for slopes, recasting the experiment as a nonequivalent groups design, the effects of the intercepts on the slopes were found to be both statistically significant and substantial in magnitude. (ABSTRACT TRUNCATED)