Learning from managed care in mental health

Dr Richard Ford

Director

Managed care system

• Care programme approach for all people in contact with specialist mental health services – originally called case or care management (1991 onwards)– Key worker, care plan and reviews

• National Service Framework/NHS Plan/LDP Targets

– Assertive outreach teams for the most severely ill 20,000 people

– Crisis resolution and home treatment for 100,000 people per annum

– Early intervention in psychosis for 7,500 people per annum

Care programme approach/case management

• May be necessary component of other models but ineffective on its own

• Can help to keep people in contact with services

• Increases use of hospital beds

• No outcome benefits – clinical or quality of life

• Unpopular with clinicians and therefore difficult to implement

Assertive outreach/assertive community treatment

• Well validated model (Cochrane review)

• Can help to keep people in contact with services

• Decreases use of hospital beds if targeted at high users

• Clinical and patient satisfaction outcome benefits

• Popular with clinicians and relatively easy to establish

• Can be difficult to sustain effective service

• Lesson – hit target group + assertive + community + treatment

Crisis resolution and home treatment• Well validated model (Cochrane review)

• Decreases use of hospital beds if targeted at people at risk of hospital admission

• Clinical, patient and carer satisfaction outcome benefits

• Initially unpopular with clinicians and complex to establish

• Must be multi-disciplinary including medical input, emphasis on intensive home treatment for several weeks and not just assessment, must act as the filter to all potential admissions

• Lesson – fidelity to model or opposite to intended impact

Early intervention in psychosis• Similar to assertive outreach but for young people

• Evidence base for minimising duration of untreated psychosis – better long term prognosis

• Limited evidence base for service models

• Popular service but numbers small and difficult to establish to rural and low prevalence areas

• Lessons – too early

Conclusions

• Case management may be necessary but is not sufficient

• It is not the model but the effective interventions within it that have impact

• Must hit the target group – all too easy to miss

• Fidelity to evidence based models important, but makes implementation more difficult

• You don’t get it right first time and things change all the time – continual review for people and services