Intensive case management for severe mental illness

Abstract

Background Intensive Case Management (ICM) is a community based package of care, aiming to provide long term care for severely mentally ill people who do not require immediate admission. ICM evolved from two original community models of care, Assertive Community Treatment (ACT) and Case Management (CM), where ICM emphasises the importance of small caseload (less than 20) and high intensity input. Objectives To assess the effects of Intensive Case Management (caseload <20) in comparison with non-Intensive Case Management (caseload > 20) and with standard community care in people with severe mental illness. To evaluate whether the effect of ICM on hospitalisation depends on its fidelity to the ACT model and on the setting. Search methods For the current update of this review we searched the Cochrane Schizophrenia Group Trials Register (February 2009), which is compiled by systematic searches of major databases, hand searches and conference proceedings. Selection criteria All relevant randomised clinical trials focusing on people with severe mental illness, aged 18 to 65 years and treated in the community-care setting, where Intensive Case Management, non-Intensive Case Management or standard care were compared. Outcomes such as service use, adverse effects, global state, social functioning, mental state, behaviour, quality of life, satisfaction and costs were sought. Data collection and analysis We extracted data independently. For binary outcomes we calculated relative risk (RR) and its 95% confidence interval (CI), on an intention-to-treat basis. For continuous data we estimated mean difference (MD) between groups and its 95% confidence interval (CI). We employed a random-effects model for analyses. We performed a random-effects meta-regression analysis to examine the association of the intervention’s fidelity to the ACT model and the rate of hospital use in the setting where the trial was conducted with the treatment effect. Main results We included 38 trials (7328 participants) in this review. The trials provided data for two comparisons: 1. ICM versus standard care, 2. ICM versus non-ICM. 1. ICM versus standard care Twenty-four trials provided data on length of hospitalisation, and results favoured Intensive Case Management (n=3595, 24 RCTs, MD −0.86 CI −1.37 to −0.34). There was a high level of heterogeneity, but this significance still remained when the outlier studies were excluded from the analysis (n=3143, 20 RCTs, MD −0.62 CI −1.00 to −0.23). Nine studies found participants in the ICM group were less likely to be lost to psychiatric services (n=1633, 9 RCTs, RR 0.43 CI 0.30 to 0.61, I2=49%, p=0.05). One global state scale did show an Improvement in global state for those receiving ICM, the GAF scale (n=818, 5 RCTs, MD 3.41 CI 1.66 to 5.16). Results for mental state as measured through various rating scales, however, were equivocal, with no compelling evidence that ICM was really any better than standard care in improving mental state. No differences in mortality between ICM and standard care ...

Self-care support for children and adolescents with long-term conditions: the REfOCUS evidence synthesis

“…length of hospital stays) and costs can often demonstrate significant skew because many patients report low costs, but a small proportion can have disproportionately high levels of use. In line with other published reviews, 26,71 we identified all outcomes where the SD multiplied by two was greater than the mean, as in these cases it is argued that the mean is not a good indicator of the centre of the distribution. 72 When studies reported multiple comparisons that were eligible for the same meta-analysis (e.g.…”

Innovative patientenzentrierte Versorgungssysteme

“…Allerdings entstehen durch das aufwendige Setting vergleichsweise hohe Kosten, sodass vor allem Patienten mit häufigen stationären Aufnahmen (>50 Tage pro Jahr) profitieren [24] und das ACT aus gesundheitsökonomischer Perspektive folglich nicht für Patienten mit seltenen Krankenhausaufenthalten empfohlen werden kann [15]. Ferner bietet sich ACT vor allem in Ballungszentren, weniger in ländlich geprägten einwohnerschwachen Regionen an [3], wenngleich für den ländlichen Raum z.…”

“…Im Cochrane-Review zum ICM [15] wurden schließlich ACT-und CM-Ansätze unter dem Begriff des Intensive Case Management subsumiert, solange der Betreuungsschlüssel kleiner als 1:20 war, was jedoch keinen allgemeingültigen Konsens darstellt [48].…”

Depicting current case management models

“…Case managers have caseloads of about 20 patients or less, direct contact with patients (Burns et al, 2007) and are clinicians in charge of providing comprehensive treatment, rehabilitation and support services (Scott & Dixon, 1995) together with their CM responsibilities (Marshall, 2008). ICM models aim to maintain patient contact with services, decrease hospital admissions and enhance results (Dieterich, Irving, Park, & Marshall, 2010). Non-ICM models include most of the features of ICM models but a caseload size of over 20 patients.…”

“…This may be related to the fact that they used a meta-analytical approach, which has been considered to provide a more objective assessment of evidence than literature reviews, a more accurate estimate of treatment effect, and may help to better explain inconsistencies between outcomes of individual studies (Egger, Smith, & Phillips, 1997). Together with the above-mentioned Cochrane reviews, there are other reviews that use the same approach in an effort to establish CM efficacy/ effectiveness and, moreover, the Cochrane group has updated its two meta-analytic reviews (Dieterich et al, 2010). Below, there is a description of the main characteristics and results of the meta-analytic reviews conducted to establish the efficacy of CM from 1995 to 2010 (see Table 2).…”