SOK P. Final IP MSW May25 2008

Case Management/SMI 1

INDIVIDUALS WITH SERIUOUS MENTAL ILLNESS: WHAT DO WE KNOW ABOUT CASE MANGEMENT?

By

Phan Sok, MD, MPH

An Integrative Project

Submitted in Partial Fulfillment

of

The Requirements for a Master of Social Work Degree,

Rhode Island College School of Social Work

May 2008


Acknowledgements

My journey is still in a long path… This project would not be achieved without generous support from many people.

I would like to thank the Fellowship Health Resources, Inc. for allowing me to

collect data at Fall River Network. I thank Denise Amoral, regional director, Stephanie Dzialo, program clinician, all staff, program directors, and program nurses at Fall River Network for their prompt responses related to this project. I, especially, thank Joseph Dziobek, the CEO, for his commitment and moral support for my internship, and providing my tuition during Fall 2007 and Spring 2008.

I appreciate and thank Dr. Roberta Sue Pearlmutter, my professor and Integrative Project advisor, for all her help and advice with this project. Particularly, I thank Dr. Mary Ann Bromley, my professor and field instructor; and Dr. Jayashree Nimmagadda, my field supervisor, for their time, advice and guidance during my academic career, as well as introducing me to the Fellowship. I extend my sincere thanks the dean, Dr. Carol Bennett-Speight, and all my professors at Rhode Island College School of Social Work, who have taught me to become a social worker. I thank Eileen Ryan for her secretarial help to meet my needs at the school.

I cannot forget to thank Karen Cunningham, former vice president at Family Services of Rhode Island, who gave advice and introduced me to the MSW program at Rhode Island College.

I would like to thank Alan Ellis Symonds and his wife Dr. Patricia V. Symonds (anthropologist, Brown University); my wife’s relatives in Canada, Try Vannary and his family; my uncle in France Thou Bernard; my sister’s family in Cambodia, Sin Rany; and my wife’s relatives in Texas and New Hampshire, the Khiev and Keo families, and a few friends in Providence for their moral and physical support to my family’s needs here. I cannot deny my gratefulness to my friends and their families in the Rhode Island Church of Christ for their love, kindnesses, and physical support since my family fist stepped into Providence, Rhode Island. They are the Wing, Lawson, Sutherland, Fackler, Gadoury, McPhee families and others. In particular, this project may not have been initiated if I had not received the special assistance of Theodore W. Blickwedel, my classmate, and his wife Julita O. Blickwedel during our family’s financial crisis in Fall 2007. I am thankful to them for their compassion and human sensitivity to my family.

Last, all my work at the School of Social Work, Rhode Island College would not have been accomplished without my family. I present special thanks and a great amount of love to my wife Dr. Saylinda Muorng, and my older son, Pagna Sok, and my younger son, Visal Sok, for their respect, truthfulness, and encouragement of me.


េសចក�ីែថ�ងអំណរគុណ

ដំេណ ររបស់ខ�ុំគឺឋិតេនេលផ�ូវដ៏ែវងឆា� យ… ក្រមងករងរ េនះមិនអចបានសេ្រមចបានេទ

េបសិនគា� ន ករជួយទំនុកបំរងុពីបុគ�លជាេ្រចនរបូ។

ខ�ុំសូមអរគុណ Fellowship Health Resources, Inc. ក�ុងករអនុ�� តឱ្យខ�ុំយកទិន�័យេន Fall

River Network។ ខ�ុំសូមអរគុណនាយិកតំបន់ Denise Amoral ្របធានគ�ីនិក Stephanie Dzialo

បុគ�លិកទំងអស់ ្របធានគេ្រមាងនិងគិលនុបដ� យិកទំងអស់េន Fall River Network ស្រមាប់ករេឆ�យ

តបរបស់ពួកេគេទនឹង ករងរេនះ។ ខ�ុំសូមអរគុណជាពិេសសដល់េលកនាយក Joseph Dziobek

ស្រមាប់ករពុះពរនិងករគំា្រទ

េលកទឹកចិត�របស់គាត់េលកម�សិក្សោរបស់ខ�ុំនិងករផ�ល់ថវកិរស្រមាប់ៃថ�់សលក�ុងសរទររដូវឆា� ំ ២០០៧

និងនិទឃរដូវឆា� ំ ២០០៨។

ខ�ុំសូមសរេសរនិងអរគុណបណ�ិ ត Roberta Sue Pearlmutter

ជាស�ស� ចរ្យនិង្រគ�្រត�តកិច�ករខ�ុំ ចំេពះករជួយនិងករផ�ល់េយាបល់របស់គាត់េលករងរេនះ។

ជាពិេសស ខ�ុំសូមអរគុណបណ�ិ ត Mary Ann Bromley ជាស�ស� ចរ្យនិង្រគ�កម�សិក្សោ បណ�ិ ត

Jayashree Nimmagadda ជា្រគ�្រគប់្រគងកម�សិក្សោខ�ុំ ែដលឱ្យ េពលេវល

េយាបល់និងករែណនំារបស់ពួកគាត់ក�ុងអំឡុងេពលេធ�កម�សិក្សោរបស់ខ�ុំ ក៏ដូចជាករនំាខ�ុំឱ្យស� ល់ the

Fellowship។ ខ�ុំសូមអរគុណេដយេស� ះដល់្រពឹទ�បុរសបណ�ិ ត Carol Bennett-Speight និងស�ស� ចរ្យ

របស់ខ�ុំ ទំងអស់េន Rhode Island College School of Social Work ែដលបានបេ្រង�នខ�ុំ ឱ្យេទជា

Social Worker។ ខ�ុំសូមអរគុណ Eileen Ryan ក�ុងករជួយែផ�កេលខធិករ

េដម្បបំីេពញនូវរល់េសចក�ី្រត�វករ របស់ ខ�ុំក�ុងសល។

ខ�ុំមិនអចបំេភ�ចករដឹងគុណដល់ Karen Cunningham អតីតអនុនាយិកេន Family Service of

Rhode Island ក�ុងករឱ្យេយាបល់និងែណនំាខ�ុំឱ្យចូលសល Social Work េន Rhode Island College។


ខ�ុំសូមអរគុណេលក Alan Ellis Symonds និងភរយិារបស់គាត់បណ�ិ ត Patricia V. Symonds

(anthropologist, Brown University) បងប�ូនរបស់ភរយិាខ�ុំ ្រទី វណា� រ ីនិង្រគ�សរឯេទៀតេនកណាដ

ឪពុកមា របស់ខ�ុំ Thou Bernard េន�ស�កបារងំ បង�សីខ�ុំ សិុន រ៉នី

និង្រគ�សររបស់គាត់េនកម�ុជានិងបងប�ូន ភរយិា ខ�ុំេន Texas និង New Hampshire មានជាអទិ៍្រគ�សរ

េខៀវ វណា� និង ែកវ វណា� ្រពមទំងមិត�ភ័ក�ិមួយ ចំនួនេទៀតេន្រក�ង Providence

ែដលជួយជាទឹកចិត�និងថវកិដល់េសចក�ី្រត�វកររបស់្រគ�សរខ�ុំេនទីេនះ។

ខ�ុំមិនអចបដិេសធេសចក�ីដឹងគុណរបស់ខ�ុំដល់មិត�ភក�ិនិង្រគ�សររបស់ពួកេគេនក�ុង Rhode Island

Church of Christ ស្រមាប់េសចក�ី�សឡាញ់ សប្ុបរសធម៌

និងករផ�ល់ជាថវកិចប់តំងពី្រគ�សររបស់ខ�ុំបានមកដល់្រក�ង Providence ៃនរដ� Rhode Island

ដំបូងមកេម៉�ះ។ អ�កទំងេនាះមាន្រគ�សរ Wing Lawson Sutherland Fackler Gadoury និង McPhee

និង្រគ�សរមួយចំនួនេទៀត។

កិច�ករេនះមិនអចចប់បដិសន�ិបានេទ

េបសិនខ�ុំមិនបានទទួលករឧបត�ម�ពិេសសពីមិត�រមួថា� ក់ខ�ុំ គឺ Theodore W. Blickwedel និងភរយិាគាត់

Julita O. Blickwedel ក�ុងខណៈេពលែដល្រគ�សរខ�ុំ មានហិរ��វបិត�ិ នាសរទររដូវឆា� ំ ២០០៧។

ជាប�� ប់ រល់ករេរៀនសូ្រតរបស់ខ�ុំេន Rhode Island College School of Social Work

នឹងមិនអច សេ្រមចបានេទេបពំុមាន្រគ�សរខ�ុំចូលរមួ។ ខ�ុំសូមសំែដងករអរគុណដ៏ពិេសស

និងករ�សឡាញ់ដ៏ធំេធង ដល់ភរយិាខ�ុំ េវជ�បណ�ិ ត មួង សយលីនដ និង សុខ ប�� ជាកូនច្បង និង សុខ

វសិល ជាកូនប�ូន រល់ករ េគារពេសចក�ីេជឿទុកចិត� និងករេលកទឹកចិត�របស់ពួកេគមកេលរបូខ�ុំ។


Abstract

Individuals with serious mental illness often need case management because of

cognitive impairments. This study evaluated case management services delivered to 80

individuals with serious mental illness at a community-based mental heath clinic, the Fall

River Network of the Fellowship. Sixty percent of this sample of clients was male. Sixty-

six percent had been diagnosed with schizophrenia and 85% had co-morbid medical

conditions. A higher proportion of men had two or more co-morbid medical conditions

when compared to women, 71% vs. 50%, p = .07, respectively. Case management

services included help with medication independence (93%), health maintenance (74%),

socialization (36%), and household maintenance (21%). Many (64%-67%) individuals

with serious mental illness had been prescribed differential medication regimens.

Although not statistically significant, males were less likely to reach medication step two

or higher compared to females, 66% vs. 80%, respectively. The frequency of hospital

admission decreased significantly during the past ten years and two years from a mean

(SD) of 4.1 (4.68) to 1.9 (2.6), p = .000, respectively. These findings suggest that

additional efforts need to be made for more effective case management services in this

setting, especially for men, and for developing a protocol of case management related to

adherence to differential medication regimens.


Table of Contents

Page Acknowledgements ..…………………………………………………. 2

Abstract …………….….…………………………………………….. 5

List of Tables …………….………………………………………….. 8

List of Figures ……………………………………………………….. 9

Problem Statement ….……………………………………………….. 10 Introduction ……………………………………………………… 10 Literature Review ……………………………………………….. 11

Epidemiology ………………………………………………… 11 Importance of the issue ……………………………………… 11

Policy Analysis ………..…………………………………………. 15 Conceptual Framework ………………………………………….. 19

Methods …………….……………………………………………….. 21 Research Design …………………………………………………. 21 Sampling ……………………………………………………….... 21 Data Collection ………………………………………………….. 22 Limitations ……………………………………………………….. 23 Ethical Issues …………………………………………………….. 24 Data Analysis …………………………………………………….. 25

Results ……………..………………………………………………… 27 Demographics of Individuals with

Serious Mental Illness & Case Managers…………………… 27 Clinical Characteristics among Individuals with SMI ………….. 29 Case Management and Outcomes at FRN …..………………….. 32 Summary………….……………………………………………… 37 Discussion ………….………………………………………………… 38 Demographics of Clients and Case Managers …………………... 38 Clinical Characteristics of Clients ……………………………… 38 Case Management Services: ……………………………………... 40 Outcomes of Case Management …………………………………. 43 Implications for Policy …………………………………………… 44 Implications for Practice and Research ………………..……….. 44

Conclusion ……………………………………………………….. 46 References …………………………………………………………… 47


Appendices ………..…………………………………………………. 53

Acronyms

ACT Assertiveness Community Treatment

CM Case management

CM-3 3-month of case management



CMC Co-morbid Medical Conditions

CMHC Community Mental Health Centers

CMI Chronic Mental Illness

CMR Commonwealth of Massachusetts Regulations

DMH Department of Mental Health

FHR Fellowship Health Resources

FRN Fall River Network

GED General Equivalence Diploma

MDD Major Depression Disorder

OCD Obsessive Compulsive Disorder

PRISM Person-Centered, Respectful, Individualized, Strengths-Based Mission Driven

PTSD Posttraumatic Stress Disorder

SD Standard Deviation

SMI Serious Mental Illness


List of Tables

Page Table 1: Demographics of Individuals with Serious Mental Illness …..……………………………………….. 27-28

Table 2: Demographics of Case Managers at Fall River Network ………………………………………………. 29

Table 3: Clinical Characteristics among Individuals with Serious Mental Illness ……..……………………………………. 30

Table 4: Case Management Services Provided by Fall River Network …….………………………………………… 32 Table 5: The Effect of Outcomes of Case Management Services …… 35

Table 6: Trend of Hospitalizations in past Ten Years and Two Years ………………………………………. 36


List of Figures

Page Figure 1: Consumers in Different Programs at

Fall River Network ……………………………………………… 28 Figure 2: Type of Schizophrenia among Individuals with Serious Mental Illness ……..……………………………………. 31 Figure 3: Type of Schizoaffective Disorders among

Individuals with Serious Mental Illness …………………………. 31

Figure 4: Number of Co-morbid Medical Conditions ………………. 32

Figure 5: Medications Steps among Consumers …………………….. 33

Figure 6: Number and Differential Medication Regimens Prescribed to Consumers ………………………………………… 34

Figure 7: Health Care Providers Needed among Consumers ………... 34

Figure 8: Outcomes of Case Management Services at FRN over Period of Time ……..………………………………… 35

Figure 9: Number of Hospitalizations in past Ten Years and Two Years …………………………………….… 36


Problem Statement

Introduction

Serious mental illness (SMI), such as schizophrenia or schizoaffective disorder, is

a complex psychiatric disorder that has influenced human lives either directly or

indirectly. This influence affects not only those who suffer with the illness, but also the

caregivers who are family members of the ill relative. Long-term standard assessment

and treatment planning is required to assist the recovery process for individuals with

SMI, regardless of whether they live in communities or residential programs. SMI results

in economic challenges, as well as other human services costs and issues for society. One

study estimated that the total financial burden of SMI (or chronic mental illness) in the

United States in 2002 was $62.7 billion (Wu et al., 2005).

Many individuals with chronic mental illness (CMI) are able to live in the

community after discharge from a hospital. But many need supports from case

management (CM) services because they are limited in their ability to manage simple

daily tasks, for instance taking prescribed medications or maintaining daily living

activities, such as shopping, cooking, or budgeting (Björkman & Hansson, 2000, 2007;

Björkman, Hansson, & Sandlund, 2002).

To date policymakers do not fully agree on diagnostic classifications; however

SMI refers to those who are disabled by their mental illness and in need of effective

treatment (Kelly, 2002). According to the National Alliance for the Mentally Illness

(NAMI), SMI includes major depressive disorder (MDD), schizophrenia, bipolar


disorder, obsessive compulsive disorder (OCD), panic disorder, post traumatic stress

disorder (PTSD), and borderline personality disorder (NAMI, n.d.).

Literature Review

Epidemiology

Overall, the prevalence of SMI is varied. The lifetime prevalence of schizophrenia

in the United States is estimated at 1%; MDD is approximately 17%; and PTSD is 8%

(Jablensky, 1999, as cited in Pratt & Mueser, 2004; Kessler et al. 1994; Kessler, Sonnega,

Bromet, Hughes, & Nelson, 1995). Schizophrenia frequently occurs in onset during early

adulthood, and males tend to have an earlier illness-onset (Canuso & Pandina, 2007,

Castle, Sham, & Murray, 1998, Gureje, 1991).

Importance of the issue

According to Pratt and Mueser (2004), co-morbid psychiatric conditions, for

instance mood and anxiety or substance use disorders, play an important role in

diminishing the ability to recover and rehabilitate cognitive and vocational functioning

among patients with schizophrenia and schizoaffective disorder. This is because each of

these disorders may impact on or interact with the disease. The authors also point out that

the two common co-morbid disorders in schizophrenia are substance use and

posttraumatic stress disorder.

Cognitive impairment is critical among those with schizophrenia or

schizoaffective disorder, resulting from the deficit of working memory (immediate

storage and access of information), verbal memory (recall and retrieval of information),

sustained attention (difficulty to focus), as well as lack of executive function (Breier,

Schreiber, Dyer, & Pickar, 1991, as cited in Pratt & Mueser, 2004; Docherty et al., 1996;


Saykin et al., 1991; Tollefson, 1996). Individuals who suffer from SMI experience

difficulty with social and role functioning, which requires both basic level neuro-

cognitive functions like memory and attention and higher-level processing, such as

planning, organizing, reasoning, decision making, information processing, and mental

flexibility (Breier et al., 1991; Tollefson, 1996, as cited in Pratt & Mueser, 2004). The

higher-level processing is considered as executive function, which is handled primarily at

the frontal lobe of the cerebral cortex.

As Pratt and Mueser (2004) indicated, the illness pervades many aspects of an

individual’s life. Therefore, it is crucial to evaluate the commonly associated features of

clients who share the disorder, such as schizophrenia or schizoaffective disorder. The

commonly associated features include medication noncompliance, problems in social and

role functioning, housing instability, family planning, and occupational functioning (Pratt

& Mueser, 2004).

Certainly, due to the natural disease characteristics, individuals who recover from

SMI need help with case management services. Many individuals with SMI both in the

community and in residential programs require multiple levels of interventions, including

CM services. These services attempt to assist individuals with CMI to become

independent in terms of vocational and cognitive rehabilitation (Bryson & Bell, 1997)

According to Yank, Bentley, and Hargrove (1993) mental health CM models

include “Expanded Broker,” “Personal Strengths,” “Rehabilitation,” “Full Support,” and

“Clinical Case Management.” Although the models differ from each other in regard to

philosophy, assessment techniques, and range of responsibilities, the overall aims of CM

are to attain the ill client’s goals.


Björkman & Hansson (2000) reported that individuals with SMI are in need of

CM services that offer more than brokerage services and coordination. More recently

these authors investigated changes over six years of follow-up with regards to symptoms,

need for care, psychological functioning, quality of life, and social networks, using CM

services for individuals with SMI. This study found improvements in a number of clinical

aspects, quality of life, and social networks, as well as a decrease in use of psychological

services during the follow-up period (Björkman & Hansson, 2007).

Medication noncompliance is found in over half (55%) of individuals with SMI,

especially those who have been diagnosed with schizophrenia. These individuals have

significant difficulty following treatment recommendation (Fenton, Blyler, & Heinssen,

1997; Weiden et al, 1991, as cited in Pratt & Mueser, 2004). Several studies indicated

that a number of factors raise barriers to medication adherence, including substance

abuse, recent alcohol use, history of aggressive behavior, less education, prior treatment

with antidepressants, higher positive and negative total score, and paranoia about

medications (Ascher-Svanum, Zhu, Faries, Lacro, & Dolder, 2006; Chandler, Meisel, Hu,

McGowen, & Madison, 1997; Hudson et al., 2004). Poor insight about illness or disliking

the side effects of medications also contributes to medication noncompliance (NIMH,

2007). Pratt and Mueser (2004) reported that elevated symptoms levels, functional

impairments, and readmission to hospitals also cause poor medication compliance.

Co-morbid medical conditions (CMC) may contribute to outcomes of social and

role-functioning of individuals with SMI (Dixon, Postrado, Delahanty, Fisher, &

Lehman, 1999). Co-morbid medical conditions are commonly seen among mentally ill

persons (Sokal, et al. 2004). Researchers found that people with schizophrenia with poor


social and role functioning are more vulnerable to relapse and often have poor outcomes

(Penn, Mueser, Spaulding, Hope, & Reed, 1995, as cited in Pratt & Mueser, 2004). There

are a number of areas in which it is necessary to be assessed with regards to social and

role dysfunctions, such as interpersonal relationships, social problem solving, use of

leisure time, grooming and hygiene, care of personal possessions, money management,

and conflict resolution (Bellack, Mueser, Gingerich, & Agresta, 1997; Mueser & Sayers,

1992, as cited in Pratt & Mueser, 2004).

Mueser, Bond, and Drake (2001) reviewed treatment outcomes in community-

based treatment for SMI. They indicated that community interventions can improve the

long-term outcomes of these psychiatric illnesses. These interventions include Assertive

Community Treatment (ACT), family intervention, supported employment, skills

training, illness self-management, cognitive interventions (cognitive therapy for

psychosis and cognitive rehabilitation), and treatment for dual diagnosis disorders.

According to the authors, the ACT model, one of the CM models that has been

articulated, is applied to those who have SMI and are noncompliant with treatment or for

other reasons have failed to use clinical mental health services. Mueser, Bond, and Drake

(2001) reported that the positive effects of the ACT model were decreases in the use of

hospitalization in 61% of the studies (14/23); improvement in housing stability in 75%

(9/12); significant decreases in symptoms in 50% (8/16); and improved quality of life in

54% (7/13). The ACT model did not do well in increasing social adjustment and work;

for instance vocational functioning increased in only 38% of the studies (3/8).

Studies of gender difference related to demographics and clinical characteristics

with schizophrenia have been conducted widely. Individuals with schizophrenia did not


differ in terms of age, ethnicity, and education, as well as clinical characteristics

(Lindamer, Lohr, Harris, McAdams, & Jeste, 1999). But little is known with respect to

outcomes of CM services and gender difference between men and women affected by

SMI.

Policy Analysis

The Community Mental Health Centers Act (CMHC) was passed under Public

Law 88-164, Title II (NIH, n.d.). Overall, the CMHC Act of 1963 gave attention to

people in need of mental health services. Section 203 of this law states that all the states

must establish “…community mental health services needed to provide adequate mental

health services for persons residing in a State” (NIH, n.d., p. 291). After it was enacted,

the CMHC Act played a crucial role in serving individuals with mental illnesses in

communities.

Grob (2000) indicated that mental health policy in the United States has shifted

from mental hospitals to mental health clinics in communities. He pointed out that the

numbers of CMHC in United States grew sharply during the last 50 years. During the

1930’s, approximately 80% of mental hospital beds in Massachusetts were occupied by

patients with long-term care needs (Dayton, 1940, as cited in Grob, 2000). But after the

1960’s, individuals with SMI received short and intermediate-term care and treatment at

mental hospitals (Kramer, 1976, as cited in Grob, 2000). In general, the law requires that

only persons with mental illness who are dangerous to themselves or to others will be

sent to the state hospital. This also would mean that others could benefit from therapeutic

interventions at community mental health clinics (Grob, 2000).


The Commonwealth of Massachusetts Regulations (CMR) 104, section 29.00 of

Department of Mental Health (DMH) provides clearly in its scope that it “applies to the

initiation and provision of DMH continuing care services to clients in community

programs …” in which the purpose of “…DMH continuing care services are provided in

the community to adults with serious and long term mental illness …” (DMH, 1999, p.

383).

Under Section 29.04 of 104 CMR 29.00, case management services should be

provided to individuals who are eligible (some or all) through clinical criteria for DMH

continuing care services. In order to meet the clinical criteria for DMH continuing care

services, an adult individual must have mental illness that:

1. includes a substantial disorder of thought, mood, perception,…

2. has lasted, or is expected to last, at least one year; and

3. has resulted in functional impairment…

4. meets diagnostic criteria specified within the current edition of Diagnostic and

Statistical Manual of Mental Disorders,… (DMH, 1999, p. 385).

According to 104 CMR, case management services include but are not limited to

comprehensive assessment of service needs, developing and reviewing the individual

service plan, and coordinating services and (or) monitoring the coordination of DMH

continuing care services provided to individuals with mental illness. The comprehensive

assessment of service needs can be found under Service Planning, in section 29.06.

In more than 460 pages written in 104 CMR, this regulation appears not to

address the degree or qualifications of a case manager. In addition, this regulation does

not provide information about training programs that might be available prior to an


individual’s becoming a case manager, or training programs that might be in place while

an individual is in the position. In terms of gender diversity in the workplace, this

regulation fails to discuss any balance between male and female case managers.

According to the Quality Improvement (QI) Policy and Procedure Manual of the

Fellowship Health Resources, Inc. (FHR), comprehensive treatment planning guidelines

are developed with the client, based on areas of need, goals, and desires that have been

identified from the assessment process (FHR, 2007). This policy also states that “staff

(mental health counselors) should be creative in the treatment planning process and work

with the client to incorporate their preferences in developing goals, objectives, and

interventions” (FHR, 2007, p. 8). A case manager at FRN is employed under the title as

mental health counselor.

In 2005, the Fellowship implemented a new clinical approach, called the PRISM

model, which is comprised of core elements, including Person-Centered, Respectful,

Individualized, Strengths-Based and Mission-Driven. The model serves as the principal

key for clinical practices, including case management services. For instance, Person-

Centered aspects assume the inherent individuality and goodness of all people and a

treatment plan that reflects individual needs and preferences (FHR, 2006).

Although the QI policy and the PRISM model attempt to provide a comprehensive

view of treatment planning for individuals with SMI, both seem not to realize that it is

very important to assess the help needed and help received at FRN. A study conducted by

Crane-Ross, Roth, and Lauber (2000) had discussed on the importance of increasing

consensus between consumers and case managers readings needs. This means treatment

planning may not accomplish its goals based solely on the preferences of the client.


Furthermore, the policy of FHR at FRN fails to indicate how a case manager is able to

assess for help that might be needed, for instance using Axis IV of Diagnostic of

Statistical Manual IV-TR (DSM, 2000).

In addition, Fellowship Health Resources at FRN has implemented its protocol of

medication administration based on medication step procedures. The medication step

procedures can be reviewed in Appendix C. The medication step procedures are offered

as part of the Medication Administration Program (MAP) policy manual of the

Commonwealth of Massachusetts foe the DMH, Department of Public Health, and

Department of Mental Retardation (MAP, 2007).

Although the medication step procedure is a core intervention in CM services at

FRN, this procedure has never been examined for effectiveness. This procedure was

never tested for compliance before implementation. Also, this procedure has no known

reliability and validity.

For years, numbers of studies related to SMI have been conducted nationwide. To

date, however, there has been little knowledge available in social work literature in

regard to types of case management and their outcomes provided for individuals with

SMI, in particular people with schizophrenia (Bernstein & Rose, 1991; Björkman &

Hansson, 2000, 2002, 2007; Phillips, 2003; Rubin, 2004). This study analyzed case

management services delivered to individuals with SMI at the mental health community-

based clinic known as Fall River Network (FRN) in Fall River, Massachusetts. The Fall

River Network, one of the Fellowship Health Resources’ programs, has offered case

management services for individuals with SMI, through community and residential


programs, including Harbor Hill, Meadow Street, Pleasant Street, and Fulton Street, using

the PRISM model (FHR, 2006).

The Fellowship has provided both clinical and support services to people

recovering from mental illness, co-occurring disorders, and other life challenges in seven

states, including Rhode Island, Massachusetts, Maine, Delaware, Virginia, Pennsylvania,

and North Carolina. Since 1975, the Fellowship has helped many thousands of people

begin new lives of dignity and purpose, and it has developed creative solutions for

rebuilding lives and restoring hopes to the recovery of the serious mental illness (FHR,

n.d.).

Conceptual Framework

Case management is mandatory for individuals with mental illness in order to

provide help to them. However, little about outcomes or effects of case management

services for SMI is described in the literature.

Three primary research questions guided this research study. First, what types of

case management services were provided to clients at FRN? Second, what outcomes

accrued to clients who received case management services? And last, were there any

differences in intervention services or outcomes related to the demographics of the

sample?

Specifically, the study examined the following:

• Demographics of the study sample (i.e. gender, age, race, marital status, level of

education) and case managers (i.e. gender, age, level of education, and year of

service in FRN).


• History of illness of individuals with SMI (i.e. age of onset of illness, frequency

of hospitalizations in the past 10 years and two years, DSM-IV-TR diagnosis,

number of co-morbid medical conditions, and prescribed medications).

• Case management services provided during the last 9 consecutive months (i.e.

medication independence, social and role functioning (daily living skills,

household maintenance, and health maintenance), socialization, insight regarding

illness, money management, and occupational functioning).

• Effects or outcomes of case management, looking at progress in achieving the

client’s treatment goals over time at 3-months (CM-3), 6-months (CM-6) and 9-

months (CM-9) of CM.


Methods

Research Design

This research study utilized a descriptive and exploratory design to examine the

outcomes of case management for individuals with SMI at FRN of the Fellowship in Fall

River, Massachusetts. Specifically, this was a case-level research design using a

retrospective method. This means that all cases that met the inclusion criteria of the study

were reviewed based on a case report form designed for the purposes of this research.

Those eligible for inclusion in this study were adult individuals diagnosed with SMI who

had received case management services for nine consecutive months prior to December

30, 2007, either in the community program (South or North) or group home facilities of

the FRN.

Sampling

The unit of analysis in this study was at the individual level. It included

individuals with SMI, who had been active in the programs during the nine consecutive

months prior to December 30, 2007, at FRN in Fall River, Massachusetts. This purposive

sample was recruited from patient records (hard copies and electronic files). By January

2008, there were 95 individuals with SMI who had been receiving services at FRN. Of

these, 80 (84%) were active clients who met the inclusion criteria of this research,

including 48 men (60%) and 32 women (40%) (See Appendix A for a description of the

sample). A purposive sample was suitable for this research study but the results may lack


generalizability. The sample was taken from one facility and was cross-sectional in

nature. However, this was an exploratory study, so no attempt was made to infer or

describe causation.

Data Collection

The data were retrieved from the patient records at FRN of the Fellowship in Fall

River, Massachusetts, between January and February 2008. A case report form was

developed for research study purposes. The form included 36 primary items and 51 sub-

items. The case report form is divided into three sections: demographics, history of

illness, and case management activities (See Appendix B for a copy of the form). The

demographic section includes basic information about clients and case managers. The

history of illness section primarily addresses the individual’s diagnosis of SMI and

relevant information related to the disorders. The case management section is focused on

two parts, type of case management services and outcomes of services.

Most questions in the case report form used nominal level of measurement, for

instance “Yes=1, No=2” or “Single=1, Married=2, Divorced=3, Widowed=4,

Separated=5.” An ordinal level scale (from 0 to 3) was used for measuring the objectives

of the treatment goal. Zero (0) means the object was dropped out or cancelled from the

treatment plan. One (1) means the objective was not met or required further interventions

or actions in order to accomplish the needs. Two (2) means the objective was ongoing,

continued, or the individual was making progress toward a current goal, but had no

evidence of moving to a higher goal. Three (3) means the objective was met, and there

was preparation or consideration of a higher goal.


As stated earlier, the case report form was administered to retrieve individual

information, using hard copies and electronic files. Data were collected at the FRN office,

1700 President Ave., and group home facilities Harbor Hill and Pleasant Street, Fall

River, MA. Records of all individuals who met inclusion criteria were carefully examined

three times, CM-3, CM-6, and CM-9. Individual case manager information was drawn

from the organization’s Human Resources database. Because the case report form was

created for this study, its reliability and validity are not known. However, the form was

reviewed by experienced peers before implementation. The content of the questions

became much more clear in that process. The form used simple language, short questions

and no double-barreled or negative questions. Its closed-ended questions elicited data on

issues that would have required interpretation in a more open-ended format.

Limitations

Due to the nature of this research design, which did not have randomization, this

study is limited by selection bias. The sample was purposive. It was a cross-sectional

study with no control or comparison group. There was no way to know if the sample was

similar to the entire population of clients who have received case management services at

FRN, or to any other population of people with SMI.

The study also was limited by history and maturation. There is no way to know

the effects of prior treatment experiences of clients who were in the study. Nor is there a

way to know the effects of growth and development in the lives of these clients.


Instrumentation effects also limited the study. However, the internal validity of

this research study may be increased by improving measurement error in the instrument

as discussed above.

The external validity of this research study is unknown, though the purposes of

this research study were stated in a clear manner, ensuring that only relevant data were

obtained to meet the study aims. The case report form kept sensitive questions to a

minimum. Also, because it was a retrospective study using administrative data, there

were no threats as a result of socially desirable responses. In addition, only relevant

questions were used to retrieve information for research study purposes.

Ethical Issues

This study was exempt from oversight by the Institutional Review Board (IRB) of

Rhode Island College. It examined only client records without access to personal

identification of clients or case managers, such as individual names, individual social

security numbers, and client record numbers.

However, the research study had to meet the privacy standards of the Health

Insurance Portability and Accountability Act before access to patient records was

permitted. The researcher assured that clients were informed that there personal data

could be used for evaluation or research purposes.

All the data and information related to client records is stored in a safe and locked

place at the researcher’s home, where only the researcher can access the materials. All the

data and information regarding this study will be destroyed three years after the study’s

completion. The National Association of Social Workers Code of Ethics states,


“...evaluation or research should carefully consider possible consequences and should

follow guidelines developed for the protection of evaluation and research participants”

(NASW, Code of Ethics, 1996, as cited in Reamer, 1999, p. 156-7).

Data Analysis

The data were double checked to ensure the quality of data entry. The data were

then entered directly into SPSS for Windows version 15.0 for data analysis. Data analysis

was performed at different levels.

First, descriptive analysis was the major analytic method for this research study,

including frequencies, measures of central tendency, and cross tabs. Specifically,

descriptive analysis was utilized to provide the distribution of demographics of

individuals with SMI and case managers. Also, descriptive analysis was performed to

present the distribution of history of illness and case management services. Second,

crosstabs analyses were generated for comparing the differences in demographics of

individuals with SMI; the demographics of individuals with case managers; clinical

characteristics; and case management services for men vs. women). Also the crosstabs

analyses were utilized for comparison of the trends in hospitalization among men and

women.

Additionally, independent samples t-tests were utilized to compare ratio variables,

including age, age at illness onset, and duration of being in the programs. Also, a paired

sample t-test was utilized to compare the means of frequent hospitalizations during the

past 10 years and 2 years. A p value ≤.05 was considered a statistically significant test

and was based on Pearson Chi-square of 2-sided, Likelihood ratio, or 2-tailed t-test.


Finally, in-depth data analysis was generated to examine the outcomes of case

management. This research study measured the outcomes of case management, using the

formula of Cohen’s d to assess the effect at CM-3, CM-6 and CM-9. The direction of

outcomes of case management was measured based on the effect size of Cohen’s d,

testing the strength of the relationship between two variables (gender and each type of

case management).

d = MeanMale – MeanFemale / SDpooled,

Where SDpooled = √[(SDMale2 + SDFemale

2) / 2].

The effect of the relationships was interpreted where 0.2 is indicative of a small

effect, 0.5 means a medium, and 0.8 or higher is a large effect size (Becker, 2000).


Results

Results are presented according to gender as early analyses had indicated that

gender appeared to provide a mechanism for organizing the data.

Demographics of Individuals with Serious Mental Illness & Case Managers

Program Participants with Serious Mental Illness

The distribution of individuals with SMI demographics is shown in Table 1

below. The 80 individuals in this study ranged in age from 26 to 70 years. The mean age

(SD) of the women was 4.5 years older than that of the men, 52.1 years (9.7) vs. 47.6

years (9.4), p = .05, respectively. The gender ratio between men and women was 1.5:1. In

this study, the majority of consumers (90%) were white. Males were more likely to be

single than females, 73% vs. 56%, respectively. Only a few (6%) had an associate’s or

higher degree. Many (67%) in this sample received Supplemental Security Income. Less

than half (44%, 43%) of individuals with SMI had either Medicaid or a combination of

Medicaid and Medicare, respectively.

Table 1. Demographics of Individuals with Serious Mental Illness Characteristics Total Males Females n = 80 (%) n = 48 (%) n = 32 (%) χ2 (t)

Age: Mean (SD) 49.4 (9.7) 47.6 (9.4) 52.1 (9.7) (-2.03)* Race

Asian 6 (8) 3 (6) 3 (10) 5.3 White 71 (90) 45 (94) 26 (84) Black 2 (2) - 2 (6) Missing 1 - 1

Marital Status Single 53 (66) 35 (73) 18 (56) 4.3 Married 4 (5) 2 (4) 2 (6) Divorced 16 (20) 9 (19) 7 (22) Widowed 1 (1) - 1 (3) Separated 6 (8) 2 (4) 4 (13)

Sexual Orientation Heterosexual 75 (98) 47 (100) 28 (94) 3.2 Bisexual 1 (1) - 1 (3) Gay/Lesbian 1 (1) - 1 (3) Missing 3 1 2


(10)

(18) (20)(13)

(9) (10)

0

10

20

30

40

50

South North Group Home

Program in Services

Prop

ortio

n of

Clie

nts

(n)

Male (n=48) Female (n=32)

Characteristics Total Males Females n = 80 (%) n = 48 (%) n = 32 (%) χ2 (t)

Level of Education

No HS 39 (53) 24 (57) 15 (47) 3.3 HS/GED 30 (41) 17 (41) 13 (41) Associate 4 (5) 1 (2) 3 (9) Bachelor 1 (1) - 1 (3) Missing 6 6 -

Insurance Types Medicaid 35 (44) 19 (40) 16 (50) 4.7 Medicare 4 (5) 3 (6) 1 (3) Medicaid/care 35 (43) 23 (48) 12 (38) No Insurance 2 (3) 2 (4) - Others 4 (5) 1 (2) 3 (9)

Source of Income SSI 52 (67) 31 (66) 21 (68) 1.7 SSDI 20 (26) 11 (24) 9 (29) SSI/SSDI 5 (6) 4 (8) 1 (3) Other 1 (1) 1 (2) - Missing 2 1 1

Being in Services (Month) Mean (SD) 76.8 (50.5) 68 (51.4) 90 (46.7) (-1.98)*

Note: HS, High School; GED, General Equivalence Diploma; SSI, Supplemental Security Income; SSDI, Social Security Disability Benefits. *p = .04; .05 (t-test, 2-tailed). Source: Study data; Analysis: Phan Sok.

Overall, the mean (SD) length of stay in the program among men was shorter than

for women, 68 months (51.4) vs. 90 months (46.7), p =.05. Figure 1 shows the proportion

of consumers scattered in each program.

Figure 1. Consumers in Different Programs at Fall River Network


Case Manager Demographics

Table 2 presents the demographics of case managers who have been serving at

FRN. Among the 18 case managers, 14 (78%) were women. On average (SD) women

tended to be one and a half times younger than men, 28.6 years (6.7) vs. 42.8 years (11),

p = .07. Over one-third (39%) of these case mangers did not have a bachelor’s degree. In

this study, men were employed by FRN for a greater number of years (SD) as a case

manager than women, 10.7 years (7.1) vs. 3.5 years (1.5), although there was no

statistical significance.

Table 2. Demographics of Case Managers at Fall River Network Characteristics Total Males Females n = 18 (%) n = 4 (%) n = 14 (%) χ2 (t)

Age: Mean (SD) 31.8 (9.6) 42.8 (11) 28.6 (6.7) (2.4)* Service Programs

South 4 (22) 2 (50) 2 (14) 2.4 North 5 (28) 1 (25) 4 (29) Group home 9 (50) 1 (25) 8 (57)

Level of Education No HS 1 (5) 1 (25) - 3.9 HS/GED 6 (33) 1 (25) 5 (36) Bachelor 10 (55) 2 (50) 8 (57) Master 1 (7) - 1 (7)

Being in Services (Year) Mean (SD) 5.1 (4.5) 10.7 (7.1) 3.5 (1.5) (1.99)

HS, High School; GED,

General Equivalence Diploma. *p =.07 (t-test, 2-tailed). Source: Study data; Analysis: Phan Sok Clinical Characteristics among Individuals with SMI

Overall the mean age (SD) at the onset of illness in the study sample was 23.3

years (7.6), and age at onset of illness ranged from 13 to 48 years. Table 3 illustrates the

clinical characteristics among individuals with CMI at FRN.

In this study schizophrenia was the most frequent diagnosis for SMI (66%),

followed by schizoaffective disorder (24%), PTSD (11%), and MDD (4%). The number


of men diagnosed with schizophrenia was slightly higher than women, 69% vs. 63%,

respectively. Types of schizophrenia and schizoaffective disorders are shown in Figures 2

and 3, respectively.

Table 3. Clinical Characteristics among Individuals with Serious Mental Illness Characteristics Total Males Females n = 80 (%) n = 48 (%) n = 32 (%) χ2 (t)

Age onset illness (n=63)

Mean (SD) 23.3 (7.6) 22.3 (7) 24.2 (8.4) (-.75) Axis I 80 (100) 48 (100) 32 (100)

Schizophrenia 53 (66) 33 (69) 20 (63) .33 Schizoaffective disorder 19 (24) 12 (25) 7 (22) .1 Bipolar I 1 (1) - 1 (3) MDD 3 (4) 3 (6) - PTSD 9 (11) 4 (8) 5 (17) 1 OCD 2 (3) 1 (2) 1 (3) Others 14 (18) 9 (11) 5 (6)

Axis II 13 (16) 8 (17) 5 (16) Axis III 68 (85) 42 (88) 26 (81)

Nervous diseases 9 (12) 6 (13) 3 (10) .13 Endocrine diseases 41 (53) 30 (64) 11 (37) 5.4* Respiratory diseases 19 (25) 13 (28) 6 (20) .57 Digestive diseases 25 (33) 12 (26) 13 (43) 2.6 Cardiovascular diseases 10 (13) 6 (13) 4 (13) Skeletal diseases 5 (7) 2 (4) 3 (11) Nutritional diseases 13 (17) 8 (17) 5 (17)

Axis IV 79 (99) 47 (98) 32 (100) PEP 72 (91) 44 (94) 28 (88) .88 Others 7 (9) 3 (6) 4 (13)

Axis V (n=57)** Mean (SD) 54.7 (9.3) 52.9 (8.4) 57.3 (10.2) (-1.7)

MDD, Major Depression Disorder; PTSD, Posttraumatic Stress Disorder; OCD, Obsessive Compulsive Disorder; PEP, Psycho-environmental Problems. Others: Alcohol abuse, n = 2 (14%); alcohol dependent, n = 3 (21%); ADHD, n = 1 (7%); cocaine dependent, n = 1 (7%); poly-substance abuse, n = 3 (21%); poly-substance dependence, n = 1 (7%); and dementia not otherwise specified, n = 3 (21%). Axis II: Antisocial personality disorder and mild retardation. Axis III: Based on DSM-IV-TRTM. Nervous diseases: Head trauma, insomnia, seizure, and sleep apnea. Endocrine diseases: Diabetes Type I or II, hypercholesterolemia or lipidemia, and hypothyroids. Respiratory diseases: Asthma and chronic obstructive pulmonary disease. Digestive diseases: Gastritis, gastro-esophageal reflux disease, irritable bowel syndrome, and hepatitis B or C. Cardiovascular diseases: Atrial fibrillation and hypertension. Skeletal diseases: Arthritis. Nutritional diseases: Obesity. *p = .02 (Chi-square, 2-sided). **p = .008 (Likelihood ratio). Source: Study data; Analysis: Phan Sok.


6%

60%

8%

26%

Disorganized Paranoid Residual Undifferentiated

90%

10%

Bipolar Depressive

Many (85%) individuals with SMI also were diagnosed on Axis III. The most

frequently occurring general medical conditions were endocrine diseases (53%), followed

by digestive diseases (33%), respiratory diseases (25%), nutritional diseases (17%),

cardiovascular disease (13%), and nervous diseases (12%). Men in this study were

Figure 2. Type of Schizophrenia among Individual with Serious Mental Illness

Figure 3. Type of Schizoaffective Disorders among Individual with Serious Mental Illness

more likely to be diagnosed with endocrine diseases than women, 64% vs. 37%, p = .02.

Overall, the Likelihood ratio of average (SD) GAF score among men was lower than that

of women, 52.9 (8.4) vs. 57.3 (10.2), p = .008. Additionally, a higher proportion of men


(12)

(17)

(7)(6)

(13)

(7)

(2)(4)

0

10

20

30

40

50

60

One Two Three Four or more

Co-morbid Medical Conditions

Prop

ortio

n of

Clie

nts

(n)


had two or more co-morbid medical conditions (CMC) than women, 71% vs. 50%, (Chi-

square = 3.2) p = .07, respectively. The number of CMC is shown in Figure 4.

Figure 4. Number of Co-morbid Medical Conditions Case Management Services and Outcomes at Fall River Network

The most frequent case management service was medication independence (93%),

followed by health maintenance (74%), socialization (36%), household maintenance

(21%), daily living skills (18%), and money management (16%). Case management

services are shown in Table 4.

Table 4. Case Management Services Provided by Fall River Network Characteristics Total Males Females n = 80 (%) n = 48 (%) n = 32 (%) χ2

Medication independence 74 (93) 44 (92) 30 (94) .34 Daily living skills 14 (18) 10 (21) 4 (13) .33 Household maintenance 17 (21) 10 (21) 7 (22) .91 Health maintenance 59 (74) 35 (73) 24 (75) .83 Socialization 29 (36) 19 (40) 10 (31) .44 Money management 13 (16) 6 (13) 7 (22) .26 Occupational functioning 7 (9) 4 (8) 3 (9) - Family environment 1 (1) 1 (2) - - Others 16 (20) 10 (20) 6 (19) -

Note: Others: Attain citizenship, n = 1; discharge planning, n = 4; health lifestyle, n = 1; hygiene, n = 2; nutrition, n = 1; self-esteem, n = 1; smoke cessation, n = 1; stress management, n = 1; substance abuse, n = 1; transportation, n = 2; and sobriety, n = 1. Source: Study data; Analysis: Phan Sok


(3)

(12)(14)(15)

(2)

(12)

(10)

(6)

05

1015202530354045

Step 1 Step 2 Step 3 Step 4

Medication Steps

Prop

ortio

n of

Clie

nts (

n)


Figure 5 shows medication steps for consumers. Over one-third (34%) of men in

FRN were on step 1 while many women (80%) were in step 2 or 3 of medication

steps. Although the difference is clear, it was not significant.

Figure 5. Medication Steps among Consumers

Figure 6 below presents the type and number of medications that had been

prescribed to individuals with CMI at FRN. Many (64%) were taking at least one

psychotic medication. Two-thirds of consumers (67%, n = 70) were prescribed one or

two mood stabilizers and/or anti depressant medications. The number and types of health

care providers needed for individuals with SMI at FRN are illustrated in Figure 7.


020406080

100120

One ≥Two One ≥Two One Two ≥Three

Psychiastrist (n=80) PCP (n=80)

Specialist (n=57)

Health Care Providers

Prop

ortio

n of

Clie

nts

Male Female

010203040506070

One Two ≥Three One Two ≥Three One toFour

Five toSeven

≥Eight

Antipsychotics (n=78) Mood stabilizers/Anti-depressants (n=70)

Nonpsy meds (n=76)

Medications

Prop

ortio

n of

Clie

nts

Male Female

Note: Antipsychotics: i.e. Abilify, Risperdal/Risperdal Consta, Seroquel, Prolixin, Trilafon, & Zyprexa. Mood stabilizers/Anti depressants: i.e. Depakote, Effexor, Lamictal, Lithium, Luvox, Tegretol, Celexa, Lexapro, Paxil, Wellbutrin, Zoloft, Prozac, Cymbalta, Clonazepam, Lorazepam, & Ativan. Nonpsychiatric medications: (Exclusion) Topical cream/lotion, Inhalers, Laxative, Oral hygiene, Treatment for narcotic addiction, Antibiotics, & Cough medications. Figure 6. Number and Differential Medication Regimens Prescribed to Consumers †

Figure 7. Health Care Providers Needed among Consumers Outcomes of CM services for individuals with SMI at FRN are shown in Table 5.

I computed between-group effect sizes, comparing the males and females at CM-3, CM-

6, and CM-9, based on Cohen’s d formula:

d = MeanMale – MeanFemale / SDpooled

Where SDpooled = √[(SDMale2 + SDFemale

2) / 2]


-2

-1.5

-1

-0.5

0

0.5

1

CM-3 CM-6 CM-9

Outcomes of Case Management Services

Mea

n C

hang

ed O

ver P

erio

d of

Ti

mes

Medication Independence Health Maintenance Socialization

Household Maintenance Money Management

Table 5. The Effect of Outcomes of Case Management Services Between Group Effect Case management† CM-3 CM-6 CM-9 Size Based on M (SD) M (SD) M (SD) Cohen’s d: CM-3 CM-6 CM-9 Medication independence (n=48)

Female 1.9 (.43) 1.85 (.28) 1.8 (.43) -.2 .2 .1 Male 1.83 (.26) 1.89 (.26) 1.83 (.48)

Health maintenance (n=36) Female 1.61 (.33) 1.5 (.33) 1.6 (.5) .1 .7 .5 Male 1.63 (.5) 1.7 (.28) 1.8 (.29)

Socialization (n=18) Female 1.44 (.44) 1.59 (.43) 1.55 (.67) -.1 -.4 -.4 Male 1.41 (.66) 1.37 (.61) 1.26 (.78)

Household maintenance (n=12) Female 1.67 (.42) 1.56 (.5) 1.61 (.33) -.6 .2 .2 Male 1.34 (.74) 1.67 (.42) 1.69 (.44)

Money management (n=8) Female 2 (.0) 2 (.0) 1.9 (.17) -.7 -1.6 -1.2 Male 1.92 (.17) 1.5 (.43) 1.5 (.43)

†Sample size is varied as individuals have received different types of services. Source: Study data; Analysis: Phan Sok

Overall, based on CM-6, the effect size for medication independence and

household maintenance indicated of a small effect (.2), while health maintenance showed

a medium effect (.7) at the same period. The outcomes of CM services are shown in

Figure 8.

Figure 8. Outcomes of Case Management Services at FRN over Period of Time


(6)(4)

(13)

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(16) (19)

(12) (7)(5)

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(16)

(11)

(3)

0

20

40

60

80

0 Time 1 Time 2 Times ≥3 Times 0 Time 1 Time 2 Times ≥3 Times

Admission in past 10Ys (n=59) Admission in past 2Ys (n=67)

Prop

ortio

n of

Clie

nts (

n)

Male Female

Figure 9 presents the frequency of hospitalizations in the past ten and past two

years among individuals with SMI at FRN. Forty-six percent of males and 42% of

females had no history of admission during the previous two years. Table 6 shows the

trend of admissions among individuals with SMI at FRN. Hospitalizations among those

in the sample significantly dropped from a mean (SD) of 4.1 (4.68) in the past ten years

to a mean (SD) of 1.9 (2.6) in the past two years, p = .000 (n = 53, paired t-test).

Figure 9. Number of Hospitalizations in past Ten Years and Two Years Table 6. Trend of Hospitalizations in Past Ten Years and Two Years

Total Males Females

n = 80 (%) n = 48 (%) n = 32 (%) χ2 (t)

Frequency of Admissions Past 10 years (n=59) 1 Time 15 (25) 13 (37) 2 (8) 6.2** ≥2 Times 44 (75) 22 (63) 22 (98)

Past 2 years (n=37) 1 Time 15 (41) 12 (55) 3 (20) 4.4* ≥2 Times 22 (59) 10 (45) 12 (80)

Hospitalization (n=53) 10 years 2 years

Mean (SD) 4.1 (4.68) 1.9 (2.6) (-5.2)***

*p = .03; ** p = .01; *** p = .000. Source: Study data; Analysis: Phan Sok


Summary

In this study, CM services included medication independence (93%), health

maintenance (74%), socialization (36%), household maintenance (21%), and daily living

skills (18%). Of these, health maintenance showed a medium effect (.7) at CM-6. A

higher proportion of men had two or more CMC than women, 71% vs. 50%, p = .07,

respectively. In addition, the Likelihood ratio of average GAF among men was lower

than women, χ2= 31.1 (df = 15), p = .008. Furthermore, 34% of men were on medication

step 1, while many women (80%) were in medication step 2 or higher, although the

difference was not significant. Overall, differential medication regimens had been

prescribed to individuals with SMI. In addition, the average (SD) number of

hospitalizations dropped from 4.1 (4.68) in the past ten years to 1.9 (2.6) in the previous

two years, p = .000.


Discussion

Demographics of Clients and Case Managers

In this cohort, 60% (n=48) of the sample of individuals with SMI were males

(Table 1). Seventy-seven percent (n=14) of the case managers were female. Overall, one-

third of the case managers (36%, n=7) had only a GED or high school degree (Table 2).

Yet, the average amount of time (SD) that clients spent in case management services with

the women was shorter than with the men, 3.5 years (1.5) vs. 10.7 years.(7.1),

respectively.

Overall there were no statistically significant differences between men and

women in this sample with respect to ethnicity, education, sexual orientation, insurance

types, and sources of income (Table 1). At least one earlier study among older

schizophrenia patients (46 to 85 years old) showed that subjects did not differ in regard to

age, education and ethnicity (Lindamer, Lohr, Harris, McAdams, & Jeste, 1999). The

current study found men were more likely to be single, though the difference in status

was not statistically significant. This finding is consistent with an Australian study,

reporting the powerful predictors of early-onset schizophrenia were poor pre-morbid

occupational functioning, single status, and being male (Castle, Sham, & Murray, 1998).

It may also be that because males tend to have an earlier onset of mental illness, they are

more likely to be single (Eaton, 1975, as cited in Pratt & Mueser, 2004).

Clinical Characteristics of Clients

Worldwide studies in schizophrenia have suggested that men tend to have earlier

age of onset than women (Caste, Sham, & Murray, 1998; Gureje, 1991; Leung & Chue,


2000; Tang et al., 2007). In Table 3, the mean (SD) age of illness onset among males with

SMI was two years earlier than females, 22 (7.6) vs. 24 (8.4), respectively.

Overall, men and women in the sample with CMI at FRN showed an almost equal

proportion of clinical assessments. Men were more likely to be assessed with

schizophrenia (paranoid) and less likely to be assessed with schizoaffective disorder

(bipolar) than women, 64% vs. 55% and 83% vs. 100%, respectively (Figure 2). However

none of these findings were statistically significant. One study has indicated no

differences in assessment of schizophrenia between men and women (Lindamer, Lohr,

Harris, McAdams, & Jeste, 1999). Tang et al. (2007) concluded that the paranoid subtype

of schizophrenia was less common in males. Diagnosis of paranoid schizophrenia in the

current study was based on assessments completed at the state’s psychiatric practice,

Corrigan Mental Health Center, in Fall River, MA. This points to a limitation in the

current study, as there were no controls for third party assessments in this retrospective

design. However, determining a clinical diagnosis for individuals with SMI at FRN was

not practical considering the culture at the agency.

In terms of CMC, the current study found many (85%) individuals with SMI

presented with CMC. This finding is consistent with studies that showed that persons

with SMI are more likely to have CMC (Carney, Jones, & Woolson, 2006; Sokal et al.,

2004). Individual men at FRN had a higher proportion of two or more of CMC than

women, 71% vs. 50%, p = .07, respectively (Figure 4). Additionally, men were more

likely to have endocrine diseases than females, 64% vs. 37%, p = .02, respectively (Table

3). Dixon, Postrado, Delahanty, Fisher, and Lehman (1999) stated that a greater number

of CMC among males with SMI independently contributes to worse psychotic symptoms,


physical health care, and a greater likelihood of a history of a suicide attempt. The results

in the current study highlight that males with SMI were at risk of poorer functional

outcomes, as suggested by Moriarty et al. (2001).

In addition, the finding (Table 1) that men at FRN were likely to be in the

program for a shorter time than women, on average 68 months vs. 90 months, may

indicate that males were delayed in accessing services. This may have occurred because

releases from a hospital and/or referral to community-based mental health outpatient

services were delayed for men. This finding supports the idea that men in this setting may

have poorer functional outcomes (Moriarty et al., 2001). However, once again, it also

reinforces the study limitations of history and maturation.

Case Management Services: Medication Steps,

Differential Medication Regimen Adherence, and Health Services

Crane-Ross, Roth, and Lauber (2000) provided a wide list of case management

services for individuals with SMI. The authors rated the amount of help needed and

amount of help received at community support service programs. The core of case

management services at the Fellowship at FRN included medication independence, health

maintenance, socialization, household maintenance, daily living skills, and money

management (Table 4). These services were mainly driven by the clinical approach called

the PRISM model, designed by the Fellowship Health Resources (FHR, 2006), as well as

the ACT model. Unfortunately, assessment of Axis IV (social and environmental issues)

was not the culture at FRN. The Axis IV data in Table 3 showed that the majority (91%)

of individuals with SMI had psycho-environmental problems. This assessment was based


on the Corrigan Mental Health Center’s assessment and it is very limited in detailing the

community support service needs for individuals with SMI at FRN. It highlights the

problem of identifying specific CM service needs in this setting. The limited use of Axis

IV at the Fellowship may explain the missing insights into individual illnesses and CM

services in this setting.

This study found that the majority of the sample (93%) with SMI needed help

with medications, with only a small difference between males and females, 93% vs. 94%,

respectively (Table 4). This finding means that many individuals with SMI were

concerned about medication adherence.

Over half (55%) of individuals with SMI had problems with medication

adherence (Fenton, Blyler, & Heiseen, 1997, as cited in Pratt & Mueser, 2004). The

current study did not have data with respect to medication non-adherence. Many

variables are associated with barriers to medication adherence among individuals with

CMI (Ascher-Svanum, Zhu, Faries, Lacro, & Dolder, 2006; Chandler, Meisel, Hu,

McGowen, & Madison, 1997; Hudson et al., 2004; NIMH, 2007; Pratt and Mueser,

2004). Some have suggested that medication adherence among those with psychosis is

associated with their level of insight into the illness (Droulout, Liraud, & Verdoux 2003,

NIMH, 2007). However, no individuals with SMI at FRN had received treatment

planning regarding insight into their illness during the last nine consecutive months. This

may raise the question of medication adherence as well as the medication step issue.

As stated in the problem statement, the medication step procedures are limited in

assessing how an individual with SMI complies with all medication regimens. Many

(64%-67%) individuals with CMI must take at least one antipsychotic, and/or mood


stabilizers and/or an anti-depressant medication at FRN (Figure 5). In addition, roughly

one-third (27%) were put on non-psychiatric medications because of the high proportion

of CMC (85%, Table 3). Thus, it is clear that many individuals with SMI at FRN needed

differential medication regimens.

Many standardize scales for evaluating compliance and attitude toward

medications among individuals with CMI are available (Hogan, Awad, & Eastwood,

1983, Weiden et al., 1994, as cited in Pratt & Mueser, 2004). Piette, Heisler, Ganoczy,

McCarthy, and Valenstein (2007) reported using medication possession ratios to assess

differential medication-regimen adherence, including antipsychotics and nonpsychiatric

medications.

With respect to medication steps, the current study also found that men were less

likely to be in medication step 2 or higher than were women, 66% vs. 80%, ns (Figure 7),

again suggesting that those men may have poorer functional outcomes.

Crane-Ross, Roth, and Lauber (2000) reported that individuals with schizophrenia

had greater needs for and received more assistance with medical and dental care. As

mentioned earlier, some studies have shown that individuals with SMI are more likely to

have CMC (Carney, Jones, & Woolson, 2006; Sokal et al., 2004). Many (74%)

individuals with SMI in the current study needed help with health maintenance through

CM services. The majority (85%) of people in this sample had CMC (Table 3). At least

one study of the use of general medical services found high levels of service use among

clients at outpatient settings, but very low levels of primary and preventive services

among individuals with CMI (Salsberry, Chipps, & Kennedy, 2005).


Outcomes of Case Management

Sun, Liu, Christensen, and Fu (2007) estimated that the national re-hospitalization

costs related to medication non-adherence amounted to $1.479 million. Another study

found that there are roughly 87,000 annual acute care inpatient admissions among

Medicaid schizophrenia patients, comprising approximately 930,000 hospital days, and

costing $806 million (Marcus & Olfson, 2008).

Interestingly enough, CM services had some effect on medication independence

(d = .2), health maintenance (d = .7), and household maintenance (d = .2) (Table 5),

particularly at six months. In addition, the current study showed that the admissions trend

rates among individuals with SMI dropped significantly (Table 6), from a mean (SD) of

4.1 (4.68) in the past 10 years to a mean (SD) of 1.9 (2.6) in the past two years, p = .000,

(n = 53). Björkman & Hanson (2007) also found there was a diminishing use of

psychological services during the follow-up period. As reviewed by Mueser, Bond, and

Drake (2001), the effects of the ACT model included decreases in accessing

hospitalization in 61% or 14 of 23 studies.

The findings that men with SMI were more likely to have lower rates of being

admitted two or more times in the past ten and two years compared to women with SMI,

63% vs. 98%, and 45% vs. 80%, p = .01 and p = .03 respectively, may be because women

stayed in the programs for a longer period of time than men, an average of 68 months

(51.4) vs. 90 months (46.7) p = .05 (Table 1).


Implications for Policy

The results of the distribution of education among the case managers in this study

suggest that a minimum education level should be specified in the regulation of 104 CMR

in order to strengthen CM services at community mental health organizations. The title of

mental health counselor for a case manager at FRN may require a credential for assuming

counselor roles. The idea of a credential is not stated either in the regulations of 104

CMR nor the Quality Improvement Policy and Procedure Manual of the Fellowship.

In addition, as discussed about CM services, both 104 CMR and the Quality

Improvement Policy and Procedure Manual of the Fellowship should be reviewed to

determine whether assessing for Axis IV is necessary to improve assistance provided to

individuals with SMI. Also, the findings about CMC highlight that the Fellowship at

FRN might consider extending its knowledge about this matter.

Furthermore, a new policy related to differential medication management should

be established at FRN since the current policy of the Fellowship does not address this

issue. Finally, a policy for medication step procedures may be revised or established if

further evaluations suggest doing so.

Implications for Practice and Research

Several implications related to the results of this study are suggested below:

1. The contradictions between clients and case managers with respect to gender, low

level of education, and length of time in case management services at FRN may raise

an issue of effectiveness of CM services. This matter has been raised infrequently in

previous literature. Providing professional knowledge (for instance, collaborating


with the Case Management Certificate Program at the School Social Work, Rhode

Island College) for case managers, as well as balancing the issue of gender diversity

at the workplace may enhance the effectiveness of case management. Further study is

needed to investigate in detail whether the case manager and client gender

differences, case manager level of education, and experience in CM have an impact

for case management outcomes.

2. Clinical diagnosis by independent clinicians at FRN should be reviewed regularly and

re-evaluated. Discussion should occur with the Corrigan Mental Health Center in

order to maintain reliability of the diagnosis with other findings.

3. Every effort should be made to encourage effective case management strategies at

FRN, especially with male schizophrenic clients, since the results of this study have

highlighted that men may be at risk of poor social and role functioning.

4. The lack of assessment on Axis IV at FRN may affect CM services as well as goals

and objectives of treatment planning. Axis IV should be assessed at FRN. This study

did not attempt to examine CM service satisfaction in regard to help needed and help

received. Additional studies are needed to investigate this issue.

5. The current study did not investigate factors that might be barriers to medication

independence. Additional studies could examine this issue.

6. This study has insufficient knowledge of the use of general medical services. Further

studies could attempt to gain a more full understanding of this issue at the Fellowship

at FRN.


Conclusion

Case management at FRN was shown to be somewhat effective, particularly for

household maintenance. The reduction of admission rates among these individuals

reflects the efforts of programs at FRN that delivered services to individuals with SMI.

However, it is difficult to understand whether the outcomes of CM resulted from the

clinical approach called the PRISM model, the ACT model of CM, or other factors.


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Appendix A

Sampling Procedure

†All were in the program less than nine consecutive months.

Fall River Network

Eligibility n = 80 (84%)

Exclusion† n = 15 (16%)

Total N = 95

South Region n = 23 (29%)

North Region n = 27 (34%)

Group Homes n = 30 (37%)

Female n = 32 (40%)

Male n = 48 (60%)


Appendix B

Case Report Form (Questionnaire)

Outcomes of Case Management: Individuals with Serious Mental Illness (SMI) Date of Data Collection [_ _/_ _/_ _] (MM/DD/YY) Client Enter Code [FRN- _ _ _] (FRN-X00) Program in Service [_] (South=1, North=2, Group homes=3,

nk=9) I. Demographic Sections A. Study Populations (select only one) 1. What is the gender? [_] (Male=1, Female=2, Other*=3, nk=9) *specify_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 2. What is the race? [_] (Asian=2, White=3,

Black=4, Hispanic=5, nk=9) 3. What is the date of birth? [_ _ _ _] (YYYY) 4. What is the current age? [_ _] (YY) 5. What is the present marital status? [_] (Single=1, Married=2, Divorced=3,

Widowed=4, Separated=5, nk=9) 6. What is the sexual orientation? [_] (Bisex=1, Gay/Lesbian=2, Hetero=3,

nk=9) 7. What is the highest level of education? [_] (No GED or HS= 1, GED or HS=2,

ASS=3, BAC=4, > Master=5, nk=9) 8. What is the insurance coverage? [_] (No insurance=1, Medicaid=2,

Medicare=3, Other*=4, >Two Insurances=5, 2&3=6, nk=9)

*specify_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 9. What id the current sources of income? [_] (SSI=1, SSDI=2,

Work=3, Other*=4, 1&2=5, nk=9) *specify_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ B. Case Manager (CM) at FRN (select only one) 10. Use of CM [_] (Yes=1, No=2, nk=9) If YES, 11. What is the CM’s gender? [_] (Male=1, Female=2, nk=9) 12. What is the CM’s age? [_ _] (YY) 13. What is the CM’s highest

level of education? [_] (No GED or HS= 1, GED or HS=2, ASS=3, BAC=4, > Master=5, nk=9)

14. How long the CM has been serving in FRN? [_ _] (YY, nk=99)

II. History of illness Section 15. When was the onset illness? [_ _] (YY, nk=99) 16. Hospitalizations in past 10 years [_] (Yes=1, No=2, nk=9) If YES,

16.1 Frequency of admissions [_ _] (nk=99) 16.2. Longest period of admission [_ _] (MM, nk=99)

17. How long has been seeing at FRN [_ _ _] (MMM, nk=999)


18. Has diagnosis on Axis I (SMI) [_] (Yes=1, No=2, nk=9) 18.1. If YES (check all applied)

a. Schizophrenia [_] (Yes=1, No=2, nk=9) b. Schizoaffective d/o [_] (Yes=1, No=2, nk=9) c. Bipolar I [_] (Yes=1, No=2, nk=9) d. Bipolar II [_] (Yes=1, No=2, nk=9) e. MDD [_] (Yes=1, No=2, nk=9)

f. PTSD [_] (Yes=1, No=2, nk=9) g. OCD [_] (Yes=1, No=2, nk=9) h. Other specify_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

19. Has diagnosis on Axis II [_] (Yes=1, No=2, nk=9; current) Yes, specify_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Yes, specify_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Yes, specify_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

20. Has diagnosis on Axis III (CMC**) [_] (Yes=1, No=2, nk=9; current)

(Numbers of CMC [_ _]) Yes, specify_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Yes, specify_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Yes, specify_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Yes, specify_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Yes, specify_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

21. Has diagnosis on Axis IV (PEP***) [_] (Yes=1, No=2, nk=9; current) Yes, specify_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Yes, specify_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Yes, specify_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Yes, specify_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Yes, specify_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

22. Indicate Axis V (last GAF†) [_ _ _] 23. Current using psy meds [_] (Yes=1, No=2, nk=9)

23.1. Yes, numbers of psy meds [_ _] 23.2. Yes, numbers of mood/anti

depressed meds [_ _] 24. Current using non-psy meds [_] (Yes=1, No=2, nk=9)

24.1. Yes, numbers of non-psy meds [_ _] 25. Has health provider(s) [_] (Yes=1, No=2, nk=9)

25.1. Has seen by psychiatric(s) [_] (Yes=1, No=2, nk=9)

If Yes, numbers psychiatric(s) [_ _] 25.2. Has seen by PCP(s) [_] (Yes=1, No=2, nk=9)

If Yes, numbers PCP(s) [_ _] 25.3. Has seen by specialist(s) [_] (Yes=1, No=2, nk=9)

If Yes, numbers specialist(s) [_ _] ** CMC, Comorbid Medical Conditions *** PEP, Psychosocial & environmental problems †GAF, Global Assessment of Functioning III. Case Management Sections A. Type of Services (select only one) 26. Service1 [_] 27. Service2 [_] 28. Service3 [_] 29. Other (1) specify_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _


30. Other (2) specify_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

31. Other (3) specify_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Coding: Medication independence (MI)=1, Daily living skills=2, Household maintenance=3, Health maintenance=4, Socialization=5, Insight of illness=6, Money management=7, Occupational functioning=8, Family environment=9, Other=10. 32. If service (MI)=1 [_] (step1=1, step2=2, step3=3, step4=4, step5=5) B. Outcomes CM-3 CM-6 CM-9 33. Goal of service1‡ specify_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

33.1. Objective1 [_] [_] [_] 33.2. Objective2 [_] [_] [_] 33.3. Objective3 [_] [_] [_] 33.4. Mean score1 …. …. ….

34. Goal of service2‡ specify_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _


35. Goal of service3‡ specify_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _


‡All objectives will be scored based on quarterly reviews of treatment planning. Zero “0” means the object was dropped out or stopped from the treatment plan. One “1” means the objective did not meet or require further interventions or actions in order to accomplish the needs. Two “2” means the objective was on going or continued to do well with a current goal, but had no plan for a higher goal. Three “3” means the objective met with a goal and prepared/considered for a higher goal.

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Appendix C

SOK P. Final IP MSW May25 2008

Documents

Transcript of SOK P. Final IP MSW May25 2008