of case management services have been the focus of much discussion. ... occupational therapy and the case management approach to service delivery.
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VOLUME 62 NO 1
• TERRY KRUPA • CARRIE C. CLARK
KEY WORDS Case management Mental health
Occupational therapy in psychiatry Role delineation
Occupational therapists as case managers: Responding to current approaches to community mental health service delivery
ABSTRACT
Case management has been identified as an effective
approach to service delivery which can assist persons with severe psychiatric disabilities to live in the community. The conceptualization and development of case management services have been the focus of much discussion. Occupational therapists are attempting to define their role in relation to case management. The purpose of this paper is to explore the relationship between occupational therapy and the case management approach to service delivery. The case management approach will be described including its objectives, models, functions and training requirements for case managers. A discussion of some of the philosophical, educational and professional issues facing occupational therapists in the role of case manager will be examined.
RÉSUMÉ
La gestion par cas s'est révélée une approche efficace de
la prestation des soins pouvant aider les personnes atteintes d'incapacités psychiatriques graves vivre au sein de la collectivité. La conceptualisation et le développement des services de gestion par cas ont fait l'objet d'intenses Terry Krupa, M.Ed., B.Sc.(0.T.) 0.T.(C) is an Assitant Professor, School of Rehabilitation Therapy, Queen's University, Kingston, Ontario, K7L 3N6
discussions. Les ergotherapeutes sont définir leur rôle en rapport avec la gestion par cas. Cette présentation a pour but d'explorer la relation entre l'ergothérapie et l'approche de gestion par cas pour la prestation des soins. La gestion par cas sera décrite y compris ses objectifs, ses modèles, ses fonctions,
Ca rrie C. Clark, B.Sc.(0.T.), 0.T.(C), OTR is a Lecturer, Department of Psychia-
et les exigences pour la formation des thérapeutes qui utilisent cette approche.
try, University of Toronto, and Programme Manager, Day Centre, Clarke Institute of Psychiatry, Toronto, Ontario
ergothérapeutes doivent faire face lorsqu'ils utilisent cette approche, sont
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Certains aspects philosophiques, éducationnels et professionnels auxquels les examinés.
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Although the policy of deinstitutionalization began over thirty years ago the mental health system continues to struggle with the problem of how to best meet the needs of persons with severe psychiatric disabilities living in the community. These individuals are faced with creating a satisfying life for themselves while dealing with persistent psychiatric disorders and a myriad of psychosocial problems. The service system whose mandate it is to address the needs of these individuals has been plagued by problems of fragmentation, inflexibility, lack of coordination and limited funding. In response to these issues case management has been identified as an approach to service delivery which can assist persons with severe psychiatric disabilities to achieve a satisfying and successful community adjustment. The case management approach is not unique to the mental health system. It is a service delivery approach which has been implemented to meet the needs of other populations with long term health care needs including elderly, physically disabled, and developmentally delayed individuals, as well as child welfare cases (Kerr & Birk, 1988; Rothman, 1991). There has been much discussion about the way case management services should be conceptualized and developed. In the process of developing a system of community based services for persons with psychiatric disabilities the traditional structure of institutional care which compartmentalizes service delivery by discipline has not been adopted. Rather attempts have been made to develop services which meet the daily living needs of the psychiatrically disabled' in a comprehensive and coordinated manner. Case management cuts across professional affiliations to place the client in the community as the focus, because the emphasis for service delivery should be directed to what the client wants and needs and not on how the system is currently organized to deliver services. The purpose of this paper is to explore the relationship between occupational therapy and the case management approach to service delivery for individuals with severe psychiatric disabilities. An overview of the case management approach will be provided, including objectives, models, functions and training requirements for case managers. This description will provide a background for a discussion of scime of the philosophical, educational and professional issues facing occupational therapists in the role of case manager. An Overview of Case Management The case management approach to service delivery aims to to meet all of the client's community living needs in an effective and efficient manner (Intagliata, 1982). The objectives which guide case management services, listed below, are based on the assumption
that persons with severe psychiatric disabilities can achieve a satisfactory quality of community life. 1. Client centred approach
The client is considered to be an individual with personal desires and needs. Case management services assist the client to identify personal goals and to implement strategies to meet these goals. Both the formal health care system and informal social systems may be used. Earlier descriptions of case management focused on the need for a service delivery approach which could overcome the problems of the mental health system. More recent descriptions emphasize the central position of the client in determining the need for case management services. (Anthony, Cohen, Farkas & Cohen, 1988; Kanter, 1989). 2.
Continuity
Most clients have several goals and needs and these will change over time. Success and satisfaction in the community occurs as a result of a highly interactive relationship between all aspects of a person's life. Case management aims to meet the person's needs in an integrated fashion, at any one time, and as they change over time. For example, a client who decides to pursue an educational goal may require that any or all of the following area be addressed: advocacy to facilitate admission to the programme; development of financial resources; parental support; study skills, supportive friendships and leisure pursuits; medication readjustments; compensatory techniques for specific impairments; accomodations in the classroom; and assistance with job placement upon completion of the programme (Intagliata, 1982; Kanter, 1989; Tessler, Willis & Gubman, 1986). 3. Accessibility
Persons with severe psychiatric disabilities are often unable to make use of the opportunities, resources and supports that they require. Case management services work directly with both clients and the resources to eliminate potential barriers to effective resource utilisation (Goering, Wasylenki, Farkas, Lancee & Ballantyne, 1988; Intagliata, 1982; Kanter, 1989). 4.
Promoting independence
A common adage asserts that case management does for an individual only what s/he is unable to do for her/ himself. The goal is to assist the individual and his/her natural supports to take over, where possible, the functions and activities that are performed by case management. "Independence" for any individual can only be understood within the context of the client's personal, social and cultural life (Harris & Bergman, 1987; Kanter, 1989).
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5. Accountability Case management aims to ensure that all of a client's needs are being met in an efficient and effective manner. Outcome measures evaluate case management from a broad perspective. They address systems issues like the cost of the delivery of case management relative to other service delivery approaches, and client centred measures such as quality of life and consumer satisfaction. (Bond, Miller, Krumwied & Ward, 1988; Borland, McRae & Lycan, 1989; Goering, et. al, 1988). There are many ways a case management service can be developed to meet the above objectives, therefore there is no definitive model of case management for individuals with severe psychiatric disabilities. The lack of a commonly accepted vision of case management has been problematic. It has lead to disagreement over the definition and core concepts of case management. However these problems may be reflective of the complexities of providing individualized service delivery for persons with severe psychiatric disabilities in the community. Some models of case management have been described, evaluated and replicated and subsequently have become synonymous with case management (Borland, et al., 1989; Goering et. al., 1988; Kanter, 1989). The particular model chosen for a case management service will depend on the philosophy, mission, structure and funding of the organization (Intagliata, 1982). Thornicroft (1991) has identified several axes around which case management services can be designed (Table 1). Understanding a case management service in relation to each of these axes provides a description of the service being offered. For example, case management services A and B can be compared along several axes. Case managers on service A are assigned a "case load" of clients and work primarily one on one with these clients. The case managers perform mostly brokerage functions. They involve their clients in determining goalsand needs and in making referrals to the appropriate services. Service A operates,during office hours. Clients are able to to access other required resources (eg. crisis or emergency services), as required, after hours. In service B the clients are assigned an identified case manager but also have contact with the other members of a case management team. The case managers provide direct service functions in addition to brokerage functions. Client participation in all aspects of the service is highly valued. Service B case managers are available to the clients on a 24 hour on-call basis for assistance they may require after traditional working hours. Traditionally case managers have assumed "service brokerage" functions. These functions include the assessment of client need, the development of a comprehensive service plan, linking the client to the 18 * AVRIL 1995
Table 1 Axes to define case management in practice Individual/Team Case Management
2
Direct Care/Brokerage
3
Intensity of Intervention
4
Degree of Budgetary Control
5
Health/Social Service Function
6
Status of Case Manager
7
Specialization of Case Manager
8
Staff:Patient Ratio
9.
Patient Participation
10. Point of Contact
1 1 . Level of Intervention 12. Target Population From "Case management in long term mental illness" by G. Thornicroft, 1991, International Review of Psychiatry, 3, p.129. Reprinted by permission.
required resource, advocating for services, and evaluation and follow-up (Anthony et. al., 1988; Intagliata, 1982; Lamb 1980). Some authors have argued that these brokerage functions do not adequately reflect either the needs of persons with severe psychiatric disabilities, nor the scope of functions which are actually performed by case managers (Bachrach, 1989; Wright, Sklebar, & Heiman, 1987). For example, these basic functions do not take into account such factors as: it may take months to form a working relationship with a client; there may be no resources available to arrange; crises can occur at any time; or the required resources may not be available to the client when s/he needs them. As a result of the inadequacies of the brokerage model of case management models have 'been developed which expand the functions engaged in by case managers working with persons with severe psychiatric disabilities. These expanded visions give case managers responsibility for more direct service and systems oriented functions. Table 2 identifies some of the functions which are frequently included in this expanded vision (International Association of Psychosocial Rehabilitation Services, 1991; Kanter, 1989; Harrod, 1986; Intagliata, 1982; Intagliata & Baker,
1983). There has been much discussion about the nature of the training which should be required of case managers. Articles in the social work and nursing literature have articulated the compatibility of these disciplines with case management (National Association of Social Workers Case Management Task Force, 1984; RobertsDegennaro, 1987; Mound, Gyulay, Khan & Goering, 1991; Lapierre & Padgett, 1992). It is not surprising that
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Table 2 Expanded functions of case management Outreach 2.
Individual counselling/supportive psychotherapy
3.
Family counselling and teaching
4.
Assistance with activities of daily living
5.
Skill development
6.
Crisis management
7.
Developing social networks
8.
Health education/counselling
9.
Resource/service development
10. Individual/systems advocacy 1 1 . Public education
different mental health disciplines have explored their relationship to case management. The functions which case managers perform, particularly in the expanded model, reflect attitudes, knowledge and skills which are typically acquired through education in any of these mental health disciplines. Furthermore, case management services may have a particular philosophy or orientation. For example a service may have a focus on systems development and change, a rehabilitation perspective, or a strong focus on illness management, or a combination of these. This lends itself to each mental health discipline identifying with those aspects of case management that are consistent with their own philosophy and models of practice. Complicating the training issue further is the fact that paraprofessionals with education and experience in the human services have been functioning as case managers. The use of paraprofessionals may be partly explained by the difficulties in attracting the required number of mental health professionals to fill case management positions. Professionals moving from hospital to community funded positions have often had to accept a reduction in pay. Also there has been a negative status given to providing the type of assistance that persons with psychiatric disabilities may require to help them manage on a day to day basis in the community (Krupa, Murphy & Thornton, 1986). Some authors have suggested that when the model of case management practiced is intensive, and requires a high level of clinical competancy, case managers should be professionally trained (Kanter, 1989). Others have suggested that paraprofessionals may be valuable assistants to case managers who have the primary clinical responsibility (Lamb, 1980). Case management services for the severely psychiatrically disabled are developing within a mental
health system which has become increasingly aware of, and sensitive to, the right and ability of consumers of mental health services to be involved in the provision of the services which they receive. (Clark, Scott & Krupa, 1993). In fact, many consumers and professionals believe that the name "case management" is patronizing and degrading and contributes to the stigma that individuals with psychiatric disabilities are incompetent. It has also been argued that the functions and activities typically performed by case managers have developed from a clinical perspective, and that these are not necessarily consistent with the needs and experiences of consumers. Everett & Nelson (1992), for example, found that clients in their case management programme did not need assistance with learning daily living skills, a service typically offered by case managers. They found that clients were more in need of assistance with problems resulting from abuse and neglect, problems for which the case managers were unprepared. There is a growing interest in exploring the extent to which case management services can be consumer driven. Consumer driven case management refers to consumer control over the development, implementation and evaluation of services. While it has been assumed that consumers lack the benefits of formal training it has also been recognized that they bring valuable knowledge and "lived experience" and they have been employed in case management positions (Nikkell, Smith & Edwards, 1992; Paulson, 1991). Therefore consideration needs to be given as to what consumer driven case management services would look like. There are several questions that come to mind: How would case management be defined?; What types of services would be provided?; In what environments would case management be offered?; Who ultimately would have policy and budget control? It should be remembered that case management is an approach to service delivery. It is not the sole domaine of any one group of practitioners. Each prospective case manager, regardless of background training or experience, should compare his/her own attitudes, knowledge and skills in relation to the specific model of case management being practiced. Identifying strengths and weaknesses provides the case manager with the information needed to seek further training or preparation to take on the functions of case management. Kanter (1989) has suggested that given the complexity of the functions and responsibilities of case management for the severely psychiatrically disabled, case management should be considered a specialized field of practice. Case management services demonstrate varied approaches to dealing with the discrepancies in the knowledge and skill base of their case managers. One case management service may require that all case APRIL 1995 19
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managers develop a significant level of competence in all case management functions (Wasylenki, Goering, Lancee, Ballantyne, & Farkas, 1985). Another programme may require that case managers develop competence in the brokerage functions of case management and retain a discipline specific function as a consultant, or provider of direct service in their area of expertise (Mound, et al., 1991).
OCCUPATIONAL THERAPY AND CASE MANAGEMENT In Canada, occupational therapists have had significant involvement in the development and implementation of case management services for persons with severe psychiatric disabilities. Occupational therapists have functioned as case managers, case management supervisors and directors of case management services. This is consistent with the movement within the profession to explore innovative models of service delivery which can help to bridge the gap between the current health care system and the client's ability to achieve success in everyday life in the community
(Carswell-Opzoomer, 1990). The philosophical assumptions on which occupational therapy is based are consistent with the principles of the case management approach to service delivery for the severely psychiatrically disabled in that they both espouse a holistic view, promote independence, and focus on functioning rather than on treating illness. In addition they share a belief that clients are central to the process of care. The client, in collaboration with the practitioner, determines the direction for service delivery (Canadian Association of Occupational Therapists, 1991; Clark, et al., 1993). Occupational therapists have a long history of addressing the functional needs of persons with persistent and pervasive mental disorders. The unique feature of the profession of occupational therapy is its focus on the individual as an occupational being and on enhancing occupational performance. Defined as having three areas of concern, self-care, leisure and productivity, the concept of occupational performance is very relevant to the the community adjustment and integration of persons with severe psychiatric disabilities. (Klasson, 1989). Occupational therapy is particularly applicable within a case management service that practices the expanded model and has a rehabilitation focus. Occupational therapists receive a specialist level education and experience in the functions which are considered integral to such a case management service. By engaging clients in real occupations, occupational therapists enable clients to develop a sense of personal meaning and purpose in their lives and to find success and satisfaction in their occupational performance. (Canadian Association of Occupational Therapists, 1993). Specifically occupational therapists are 20
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trained to perform the following functions in partnership with the client: functional assessments; occupational analysis; skill development; identifying and eliminating factors which impede functioning; compensatory techniques; environmental assessments; and changing environments to enhance successful and satisfying performance. In addition occupational therapy training in the physical and cognitive aspects of occupational performance is useful to a case management service because individuals with severe psychiatric disabilities often have impairments in these areas which require attention. Occupational therapists are less well prepared for taking on some of the other functions performed by case managers. The functions of the traditional brokerage model of case management describe the process of identifying, accessing and coordinating the services that are required to meet all of the client's needs. Occupational therapists are skilled at identifying service needs that are beyond their scope of practice and referring clients on to the appropriate resources. However, in response to studies which indicate that people with severe psychiatric disabilities are not likely to connect with the services to which they are referred, some authors have suggested that these brokerage functions are complex and require a specialized level of knowledge and skill development (Cohen, Anthony, Pierce & Cohen, 1977; Krupa, Singer & Goering, 1988). Other case management functions for which occupational therapists are less well prepared include: 1. Health education and counselling, specifically medications and other medical treatments. 2. Crisis management. 3. Family assessments and interventions. 4. Resource and service development as well as interagency coordination. 5. Changing systems by advocacy and lobbying. While these areas have received more attention in the baccaulaureate occupational therapy programmes in the past decade, they have not typically been considered within the domaine of the profession. Occupational therapists working as case managers will need to improve their knowledge and skill base in these areas. While this may be accomplished through workshops, courses and other formal educational programmes, many case management programmes will provide the resources and support their staff require to function successfully as case managers. For example, the occupational therapists working in one case management programme did not feel prepared to assess and manage the crisis situations with which they were presented. However when the administration of the programme clarified the lines of responsibility and the performance requirements of case managers for crisis management the occupational therapists felt
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better prepared to deal with these situations. In the same programme the case managers who were particularly skilled in family assessment and intervention not only provided consultation services, but also training opportunities for those case managers who wanted to develop these skills. Given the profession's committment to community practice an increasing number of occupational therapists will likely consider employment within the case management model of service delivery. Certainly there are aspects of case management with individuals who have severe psychiatric disabilities that many occupational therapists will not find appealing. Therapists may find that the sharing of functions with case managers who are not occupational therapists creates a sense of role ambiguity and conflict. Occupational therapists are familiar with the persistent nature of psychiatric disorders and the severe impact on client functioning. However, occupational therapists who are case managers will come face to face with the lack of supports, the poverty, the stigma and discrimination that place these clients on the social fringes of their communities. These factors can be shocking and undesirable conditions for employment. It can be argued that these conditions, when coupled with the level of autonomy and responsibility required of case managers, are not suitable for new graduates of occupational therapy programmes because of their limited work experience. Of course the opposite argument may also be valid. Working in institutional environments may provide new graduates with structure and a relatively safe environment, but it may also negatively bias the therapists perspective on what clients can realistically be expected to accomplish. There is another perspective on case management, the one which reflects the view of occupational therapists who are very satisfied in these positions. Case management, particularly the expanded models of case management, allows the therapist the opportunity to develop a particularly close working alliance with an individual client. The ability to establish an alliance is contrary to the popular belief that these individuals are too withdrawn and emotionally unstable to engage in close interpersonal relationships. Within these relationships the case manager has the opportunity to experience a full range of rewarding human emotions, joy, sorrow, pride, love, respect and trust, to name but a few (Krupa, 1994; Munroe-Blum, 1994). The therapist is allowed the time required to see change and growth. Identifying and building on a client's strengths is easier when the client is engaged in daily life within the community. Working in the client's natural environment increases the likelihood that changes will be integrated into the person's everyday life. The level of autonomy and responsibility experienced by case managers requires creativity,
ongoing knowledge and skill development, and collaboration with a wide variety of people within and outside of the formal mental health system. From this perspective case management can provide occupational therapists with a strong sense of credibility and professional identity.
CONCLUSION This paper has described the case management approach to service delivery for persons with severe psychiatric disabilities. The objectives of case management are to assist these persons to achieve success and satisfaction in community life by offering: a client centred approach; continuity of care; accessibility to resources; opportunities for independence; and accountability. Although there is no definitive model of case management, various models have been articulated and evaluated. The functions provided by case managers range from service brokerage functions to a comprehensive array of direct care and systems oriented functions. The ideal training requirements for case managers is an ongoing issue. Professionals, paraprofessionals and consumers have all functioned successfully as case managers. Evaluating attitudes, knowledge and skills in relation to a specific case management model is the key to becoming an effective case manager. Occupational therapists are currently invoved in developing and implementing case management services for the severely psychiatrically disabled. The philosophical assumptions which underlie occupational therapy are consistent with the principles on which the case management approach is based. The unique contribution of occupational therapy is the specialized level of academic and skill training related to occupational performance..However there are case management functions, specifically, health education, crisis management, resource development, family interventions, systems level advocacy and lobbying, and interagency coordination, for which occupational therapists are less well prepared. With the profession's focus on community practice, occupational therapists are in an excellent position to be case managers. For occupational therapists committed to working with the severely psychiatrically disabled, case management offers an approach to service delivery that is rewarding and challenging. Case management can provide occupational therapists with a strong sense of credibility and professional identity.
ACKNOWLEDGEMENTS The authors would like to thank Mary Managh, Susan Meikle, Judy Phillips, Sandy Henderson and Dr. Paula Goering for their valuable contributions.
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REFERENCES Anthony, W.A., Cohen, M., Farkas, M., & Cohen, B. F., (1988). Case management: More than a response to a dysfunctional system. Community Mental Health Journal, 24, 219228.
Bachrach, L. L. (1989). Case management: Towards a shared definition. Hospital and Community Psychiatry, 40, 883884.
Bond, G.R., Miller, L.D., Krumweid, R.D. & Ward, R.S. (1988). Assertive case management in three CMHCs: A controlled study. Hospital and Community Psychiatry. 39, 411-418. Borland, A., McRae, J., & Lycan, C. (1989). Outcomes of five years of continuous intensive case management. Hospital and Community Psychiatry, 40, 369-376. Canadian Association of Occupational Therapists. (1991). Occupational therapy guidelines for client centred practice.
Toronto ON: CAOT Publications. Canadian Association of Occupational Therapists. (1993). Occupational therapy guidelines for client-centred mental health practice. Toronto: CAOT Publications. Carswell-Opzoomer, A. (1990). Muriel Driver Memorial Lecture.
Our time has come. Canadian Journal of Occupational Therapy, 57, 197-203.
Clark, C.C., Scott, E.A., & Krupa, T. (1993). Involving clients in programme evaluation and research: A new methodology for occupational therapy. Canadian Journal of Occupational Therapy. 60, 192-199.
Cohen, M.R., Anthony, W.A., Pierce, R.M. & Cohen, B.F. (1977). Psychiatric rehabilitation practice: The skills of community coordinating. Amherst M.A.: Carkhuff Institute of Human
Technology. Everett, B. & Nelson, A. (1992). We're not cases and you're not managers: An account of a client-professional partnership developed in response to the "borderline" diagnosis. Psychosocial Rehabilitation Journal. 15 (2), 49-60.
Goering, P.N., Wasylenki, D.A., Farkas, M. Lancee, W.J., & Ballantyne, R. (1988).What difference does case management make? Hospital and Community Psychiatry. 39, 272276.
Harris, M. & Bergman, H.C. (1987). Case management with the chronically mentally ill: A clinical perspective. American Journal of Orthopsychiatry, 57, 296-302.
Harrod, J. B. (1986). Defining case management in community support systems. Psychosocial RehabilitationJournal, 9, 56-61. Intagliata, J. (1982). Improving the quality of community care for
the chronically mentally disabled: The role of case management. Schizophrenia Bulletin, 8, 655-674. Intagliata, J. & Baker, F. (1983). Factors affecting case management services for the chronically mentally ill. Administration in Mental Health, 11, 75-90.
International Association of Psychosocial Rehabilitation Services Ontario Chapter. (1991). Position paper on case management. Toronto ON: IAPSRS Ontario Chapter Kanter, J. (1989). Clinical case management: Definition, principles, components. Hospital and Community Psychiatry, 40, 361-368.
Kerr, M.H. & Birk, J.M. (1988). A client-centred case management model. Quality Review Bulletin, 14, 279-286.
22 • AVRIL 1995
Klasson, E. M., (1989). A model of the occupational therapist as
case manager: TWO case studies of chronic schizophrenic patients living in the community. Occupational Therapy in Mental Health. 9, 63-90.
Krupa, T. (1994). Steven and me. Psychiaby: Intopersonal and Biological Processes, 57. 174-175.
Krupa, T., Murphy, M. & Thornton, J. (1986). Treatment of the long term mentally ill. In D. Scott and N. Katz (Eds.), Occupational therapy in mental health: Principles in practice , pp 19-31. London, England: Taylor & Francis.
Krupa, T., Singer, B., & Goering, P. (1988). From hospital to community: Discharge planning for psychiatric patients. Tim Canadian Nurse. 84, 14-16.
Lamb, H. R. (1980). Therapist-case managers: More than brokers of services. Hospital and Community Psychiatry, 31, 762764. Lapierre, E.D., & Padgett, J. (1992). What does a nurse need to
know and do to maintain an effective level of case management?Journal of Psychosocial Nursing, 30, 35-39.
Mound, B., Gyulay, R., Khan, P., & Goering, P. (1991). The expanded role of nurse-case managers. Journal of Psychosocial Nursing, 29, 18-21. Munroe-Blum, H. (1994). Commentary on Krupa and Leebens. Psychiatry: Intopersonal and Biological Processes, 57, 176-177.
National Association of Social Workers Case Management Task Force. (1984). NASW standards and guidelines for social work case management for the functionally impaired.
Silver Spring, MD: National Association of Social Workers. Nikkel, R.E., Smith, G. & Edwards, D. (1992). A consumeroperated case management project. Hospital and Community Psychiatty, 43, 577-579.
Paulson, R.I. (1991). Professional training for consumers and family members. Psychosocial RehabilitationJournal, 14, 69-80. Roberts-DeGennaro, M. (1987). Developing case management as
a practice model. Social Casework.. The Journal of Contemporaly Social Work, October, 466-470. Rothman, J. (1991). A model of case management: Toward empirically based practice. Social Work, 36, 520-525. Tessler, R.C., Willis, G., & Gubman, G.D. (1986). Defining and measuring continuity of care. Psychosocial Rehabilitation Journal, 10, 27-38. Thornicroft, G. (1991). The concept of case management for
long- term mental illness. International Review of Psychiatry, 3, 125-132. Wasylenki, D.A., Goering, P.N., Lancee, W.J., Ballantyne, R., & Farkas, M. (1985). Impact of a case manager program on psychiatric aftercare. Journal of Nervous and Mental Disease, 173, 303-308.
Wright, R.G., Sklebar, H.T., & Heiman, J.R. (1987). Patterns of case management activity in an intesive community support program: The first year. Community Mental Health Joumal, 23, 53-59.
