The Trade-Offs of Developing a Case Management Model for Chronically Mentally Ill People

This article addresses the role of case management in the care of chronically mentally ill people. Trade-offs often occur because case management is frequently used to achieve the conflicting goals of reducing service use costs and raising the quality of life for clients. Despite these trade-offs, case management can be effective if it is designed so that services match client needs and the costs of services are measured accurately. Case management for chronically mentally ill people is particularly difficult to design because their level of functioning and need for intensive services are such that the cost to deliver the appropriate services is great. The profit-maximizing nature of the U.S. health care system makes some form of capitation likely in the design of case management services for this population.Financing of mental health services for chronically mentally ill people is undergoing two important changes. First, service delivery increasingly is being shifted from the public to the private sector (Davis, 1981; Kinzer, 1984). Second, over the past decade, the cost of mental health care has increased sharply (Frank & Kamlet, 1984;National Institute of Mental Health |NIMH~, 1991). A major concern for mental health policymakers in a market-oriented society is how to contain costs without significantly sacrificing the quality of care for the client (Frank & McGuire, 1986; Sharfstein & Taube, 1982). Policymakers frequently cite case management as a means for improving care and also controlling costs (Franklin, Solovitz, Mason, Clemons, & Miller, 1987; Jerrell & Hu, 1988; Wasylenski, Goering, Lancee, Ballantyne, & Farkas, 1985).Case management is primarily a function for social work that can deliver consistent services and improve the quality of care (Johnson & Rubin, 1983). However, Austin (1984, 1988) and other scholars, such as Belcher and DiBlasio (1990), Stoesz (1986), and Gilbert (1983), warn the profession that the welfare state is undergoing a significant contraction in size and scope. Consequently, they warn, government-supported services will become more punitive and restricted.Although some studies have shown case management to be an effective method to improve care (Bond, Miller, Krumwied, & Ward, 1988; Wasylenski et al., 1985), others have shown that the quality of care may be sacrificed when the goal of case management also is to control costs (Franklin et al., 1987; Morlock, Taube, & Ross, 1988). Social work professionals need to address the increasing use of case management as an instrument of cost containment because clients with persistent problems in living, such as chronically mentally ill people, may face barriers in their efforts to secure effective and consistent care (Abramovitz, 1986). Inadequate care can result in both psychiatric and social decompensation, which can place the chronically mentally ill client at risk for homelessness (Belcher, 1988c) and criminalization (Belcher, 1988a).This article examines the trade-offs between efforts to improve quality of care and efforts to contain costs. It also examines the benefits of a national health insurance system to provide care. In addition, the article develops a model of capitation that accurately reflects the needs of the client and the costs necessary to provide appropriate care.REVIEW OF THE BROKERING AND CLINICAL CASE MANAGEMENT MODELSSome studies have shown case management to be effective in increasing functioning and lowering rehospitalization rates for chronically mentally ill clients (Bond et al., 1988; Jerrell & Hu, 1988; Test, Knoedler, & Allness, 1985; Witheridge & Dincin, 1985). However, case management often has been found to be as expensive as, if not more expensive than, hospitalization (Borland, McRae, & Lycan, 1989; Franklin et al., 1987; Morlock et al., 1988). Costs often increase because of more intensive use of community-supervised residences and greater use of intensive community support services (for example, more frequent contact with a social worker). …