This article is based on my experience in case management in both hospital and community settings in the UK and Malaysia and as senior manager for a non- profit organisation in Singapore. My experience spans from 1997 to 2019.
The problem with the medical model
Only doctors are licensed to diagnose a mental illness. However, the treatment provided by them is not the be all and end all. In fact, a large percentage of patients do not keep their follow up appointments and even more do not take their prescribed medication. The medical model is where the patient presents with a set of symptoms; the doctor offers a diagnosis and prescribes medication; he may refer the patient to another health care professional for talking therapy. At a follow- up, the doctor monitors the client’s progress or the lack of it. From the perspective of the medical model, if there is a significant abatement of symptoms then the treatment is a success. If not, the doctor continues the treatment by changing the medication and adjusting the dose.
One step forward, two steps back
Sounds simple enough but in reality, this linear and seemingly perfect treatment is not so. Recovery is a process. There are good days and there are bad days. A patient may make a step towards progress and slides two steps back. More importantly in treating all types of mental illness one must look at the clients holistically. This is because mental illness affects most if not all aspects of a person’s life. The ramifications of a mental illness go beyond signs and symptoms but also include one’s social, spiritual, work, family and personal development. Let’s consider the following example:
A holistic approach
Paul was an active 24 year- old who had lots of friends, played football regularly and helped out at his church. He worked in an IT company. One day Paul started hearing voices. These voices criticised his actions constantly. He thought that people were spying on him. The voices became so bad that he could not concentrate and eventually lost his job. He started to talk to himself. His friends were afraid and stayed away from him. Paul also stopped going to church. Due to his intense anxiety and fear Paul isolated himself in his room and neglected his personal hygiene. Family members who did not understand called him ‘lazy’ and were hostile towards him. One day, he thrashed his bedroom and became aggressive toward his mother. Fearing for her safety, she called the police. They admitted him to hospital.
From the above example Paul’s onset of schizophrenia cost him his job which would affect his financial status. The illness also impacted on his social life, spirituality and hobby. His mental illness lowered his self- esteem and put a strain on his family. A doctor who spends an average of ten minutes and is trained to look for signs and symptoms would not have the time to enquire about what’s going on in Paul’s life. Arguably, addressing other aspects of Paul’s life is beyond his job scope.
While we support the idea that recovery is personal and means different things to different people, there is this universal truth that when you recover from any illness – physical or mental you would want to come back to as near your base line as possible or to what is deemed as “normal” to the person with the illness.
In treating a mental illness, a holistic approach that addresses the other needs of the clients should be at the heart of all service provision. In doing so the beneficiaries can get back on track in an impactful way. To this end health care professionals will need to work collaboratively with other professionals and the delivery of care has to be effectively customized to meet the needs of the clients. It is clear that one health care professional cannot address all those needs because no such beast exists. A doctor who adjusts the medication is not a social worker. The social worker is not a priest and cannot fulfil his spiritual needs and the priest is not his employer and so forth.
Good quality care involves comprehensive case management. It is not just the medical approach but a coordinated and combination of social work, problem solving, carer involvement, life coaching, psycho education, faith- based counselling, education counselling, back to work scheme and so forth. Whatever that is needed to make the client “whole “again.
Good quality case management involves a thorough assessment of the client’s needs by a coordinator. With the agreement of the patient, she formulates a plan of care and refers him to the necessary agencies. At a case management meeting, each professional’s role is clearly defined: who does what, when, where and how often. This information should be documented and all parties should have a copy. In an ideal world these same people should “talk” to each other and periodically meet to evaluate if the care plan has impacted the clients’ lives. If it has not then interventions must be readjusted. Case management should be needs led, not service led.
The disparity between what the client wants and what the professionals think he needs poses a challenge. As a Community Psychiatric Nurse (CPN) in the UK, I had to fight demons because what my client wanted was a continent away from what I thought was good for him. Still we have to respect our client’s wishes even though we may not agree with it (as long as it’s not too off the wall), for that is true empowerment. In formulating care plans there needs to be a fair amount of negotiating where both parties must be prepared to compromise for there to be any achievable goals. Nothing is more demoralising when unrealistic goals are set that result in failure to achieve them. When expectations differed, it was important that I maintained a general positivity and exuded calmness so that our professional relationship could be sustained.
Hit and Miss
As senior manager leading a team of counsellors in Singapore, I found that case management was not formalised. It was very much a hit and miss. Services were fragmented and some services serve only certain geographical areas. Some of my team members were not keen on case management because they did not know what it entailed, they did not have the skills, they did not want to go “that far” or didn’t think it was their role. I’ve dealt with other agencies who referred clients to our organisation because: “He’s been with us for so long” or “I don’t know what to do with him.”
Another hindrance of case management is the reluctance for agencies to share information. I’ve heard of anecdotes where different departments of a single organisation will not share information because they feared the repercussions of breaking PDPA rules. Such rules do exist in the UK but when it came to case management where collaboration was the operative word, information is often shared on a need to know basis.
In Singapore, some agencies worked in silos and many case managers struggle to come to an agreement of when to meet. I once had to change a meeting four times to accommodate other people’s schedule. If we put case management at the top of our priority list then meeting once every three months should not be an issue.
Cracking the whip
I’m also speculating that some health care workers think that case management involves them doing all the work and the idea of coordinating everyone and “cracking the whip” is a daunting one. Maybe there is this idea that only social workers can or should be case managers and that counsellors or clinical psychologist cannot case manage. This misconception must be lifted and perceptions corrected if we are to have any hope of introducing effective case management to improve the lives of people with mental illness. In the UK case managers are not confined to one profession. Doctors, social workers and psychiatric nurses like myself could be case managers.
When I was senior manager in 2019, some clients kept relapsing and were readmitted – like a revolving door. Some remained as chaotic as ever or where they reached a plateau, had not moved on. Others received identical services from different agencies and learned to “play” the system. If this was the status quo in most of the service providers in Singapore, I would not be surprised if health workers become demoralised and suffer from burn out as they take on more clients and have to manage a huge caseload because their clients rarely got better.
Case Study 1 – a successful story
This is a 50 year- old widow who had 2 children. The reason for referral was a language issue. The client suffered from schizophrenia following her husband’s death. When she became unwell, she put her children in danger and since then her children were in care. The social worker and I saw Madam Z together. We soon realised that we were doing the same work. I was about to disengage when Madam Z became unwell and was admitted. I saw Madam Z in hospital and spoke with her nurse. Already we were planning for her discharge.
When Madam Z became stable, she attended an activity centre twice a week. The accompanying occupational therapist observed her safety awareness and social skills. The social worker liaised with the foster parents to arrange Madam Z’s visit with her children. My role was to help her identify her triggers and explore strategies to cope with stress and build her resilience. We discussed her delusions, what she felt and how she behaved when she became unwell. We also explored what she wanted us to do when she became unwell again. The occupational therapist disengaged after observing that Madam Z could safely take public transport on her own. Madam Z continued to attend the centre. Meanwhile, she had discussed going back to work with the social worker who found her a job as an assistant. After a couple of months the doctor discharged her.
Continuity of care
Madam Z stopped attending the centre when she started work. I visited her at home to monitor her mood and symptoms until I disengaged months later. Madam Z continued to work, see her children at the weekends and went to the hospital for her monthly injections. There was no paperwork among us but we updated each other regularly by email. Our roles were clear and when our services were no longer needed, we disengaged. In doing so we use our resources efficiently. There was no designated coordinator but it was clear that the SW was the main man in Mdm Z’s care.
In Madam Z’s care – the health professionals were a psychiatric nurse, a staff nurse, a doctor, a social worker, an occupational therapist and the children’s home manager. Our roles were clear and we did the needful as per our area of expertise. We listened to each other’s input and respected each other’s opinion. There was psychological safety among us where we could say what we thought without fearing the repercussions. We communicated regularly and shared information.
Case study 2 – a not so successful story
I attended a case management meeting regarding a single mother who had a 5 year- old son. Sabrina (not her real name) worked as a cleaner. She became unwell with schizo-affective disorder and put her child in harm’s way. The Child Protection Unit put her child into care. The court ordered that she should comply with her care plan if she wanted her child back.
A crowded room
When I attended the meeting there were around fifteen people in the room. There were 3 people from one agency. We planned to meet earlier to discuss the issues before the client arrived. The client looked well groomed and was articulate. She stated that she felt overwhelmed by the numbers present. Half way through the meeting she stated that she “pushed to a corner” because “you all have my son”. I got the sense that she stated that she would comply with the plan because she wanted her son back. She didn’t believe she had a mental illness.
We’re doing the same thing
My role was to see her every two weeks to monitor her symptoms. She agreed to this. But I was not convinced that she would comply. When I phoned her, she stated politely that with work, rest and supervised visits with her son she simply did not have the time to see me. Her reasons were plausible. I was looking for a solution when she told me she was seeing a psychiatric nurse as an outpatient. If I were to engage, we would be doing very similar work. Despite this I phoned her three times. The client rejected my services each time.
In my email to the care coordinator I stated that my intervention cannot proceed on the grounds that there was no consent. Furthermore, there would be a duplication of services. He insisted that I try to engage. I appreciated that he was under pressure but consent is of utmost importance in what we do. And that alone is not enough. It is also important that we have the goodwill of a client. Case management isn’t just collaboration among professionals but also between clients and professionals. We can obtain consent implicitly and explicit- even under duress. However, goodwill must come from a willingness from the client to receive help. I updated my report to the team and closed the case at my end.
The role of a case coordinator
Assesses the needs of the client holistically
Makes the necessary referrals
Calls for a meeting
Document the decisions made
Collates all information given by other agencies
Shares this information
Calls for evaluation meeting and adjusts care plan accordingly
Main point of contact for all updates.
Encourage the client to bring someone for support.
Keep meetings small.
Introduce everyone and their role in the client’s care
Encourage frank and honest discussion
Discuss disagreement and find resolution at the meeting
Ensure everyone’s emails and phone numbers are accurate
Go through each point at the end of the meeting – making sure everyone is “onboard”
Make sure client has an opportunity to speak at the end of the meeting
Document all information accurately
Send out detailed care plan soon after meeting
A good case management coordinator is…
The person who has the best rapport with the client
Not be afraid to disagree and say so
Proactive in being able to anticipate challenges
Au fait with negotiating
A good communicator
Well informed of resources
Willing to learn and accept new ideas
It has become abundantly clear that there needs to be some form of leadership here. If case management is mandatory the world will be a better place. A single agency should be taking the lead in producing the following: a standardised template to document the care plan; a work flow and a comprehensive training package for all sectors. Is it audacious for me to hope that one day everyone will come on board? I hope not. We have Marina Bay Sands and The Jewel. Surely, we can provide our citizens who have mental health issues with a comprehensive care package. I am forever optimistic.
https://recovernow.com.sg/wp-content/uploads/2020/02/doctor-speaking-to-female-patient-with-brown-hair_o6pk4y.jpg6301200adminhttps://recovernow.com.sg/wp-content/uploads/2020/11/h-scaled-e1605433537391-300x104.jpgadmin2020-09-21 03:43:332020-10-13 19:57:44All of me: case management in mental health