Academic journal article Australian Health Review

Care Management for Older People with Mental Health Problems: From Evidence to Practice

Academic journal article Australian Health Review

Care Management for Older People with Mental Health Problems: From Evidence to Practice

Article excerpt


Aim: To explore the implications of providing intensive care management in a typical old age mental health service in North West England.

Methods: The time spent by core groups of specialist mental health and social services staff on a range of activities deemed central to the provision of intensive care management was explored by means of a diary exercise. The difference between what is actually being done and what evidence suggests is needed was examined.

Results: More than 1500 hours of activity were appraised. Assessment and care management-related tasks accounted for more than 40% and 30% of social work and nursing staff's time, respectively. However, several fundamental features of intensive care management were lacking, including health staff's adoption of the care manager role, arrangements to facilitate appropriate information sharing and sufficient time for practitioners to provide the necessary careful assessment of needs, liaison with other agencies, and close and regular contact with the elderly person and their care network.

Aust Health Rev 2008: 32(2): 210-222

THE INCREASED BURDEN of chronic disease associated with rising life expectancy presents a considerable challenge to policy makers around the world.1 Mental health problems, particularly depression and dementia, account for a substantial proportion of this burden.2 These disorders are common in older people, can affect every aspect of a persons functioning and are associated with increased resource use.3-6 While one might think that there would be a compelling incentive to find the most appropriate, effective and efficient ways of caring for this client group, the evidence base for many common services is, as yet, relatively undeveloped.7,8 Moreover, even where studies do indicate the effectiveness of a particular approach, this is no guarantee of its adoption in practice.9,10 The potential of intensive care management to enable older adults with mental health problems to remain at home, a fundamental aim of many countries' community care policy and most people's personal preference, is a case in point.11-15

With origins in concerns about the fragmented delivery of health and social services, case management, implemented as care management in the United Kingdom,16-18 is in essence a strategy for the organisation and co-ordination of care services at the client level. Primary tasks include case finding and screening, assessment, care planning, arranging services, monitoring and review.19 Initially a North American concept, a series of pilot studies by the Personal Social Services Research Unit (PSSRU) demonstrated improvements in older people's and carers' wellbeing and reduced admissions to long-term care, providing strong empirical support for the adoption of "intensive care management" with this client group.19,20 The key features of this approach include a differentiated response to need, appropriate links with specialist health care expertise, small caseloads and devolved budgets,21 and the model appears to have a particular utility for the care of older people with mental health problems.12,22-24 Indeed, an important lesson from the demonstration programs was that the efficacy of intensive care management lay in targeting specific groups of older people with multiple/complex needs.25 However, following the 1990 NHS and Community Care Act, which made local authority social services departments responsible for the introduction of care management in the UK, preliminary guidance17,18 implied that such arrangements should be applied to all service users. It focused attention on the core tasks of the care management process and led local authorities to focus on these as discrete entities that might be undertaken by different members of staff, rather than developing arrangements in keeping with the concept of care management as a model of long-term care as shown in Box 1. It is thus perhaps not surprising that by the end of the 20th century only 5% of local authorities had care management services specifically targeted at older people with complex needs, although there did appear to be some focus on older people with mental health problems, with mental health nurses acting as care managers in about 10% of authorities. …

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