Mental Health Nursing

Case management: perspectives of the UK and US systems 101
without walls’, providing a high-intensity programme of clinical support
and treatment.
The role of the nurse in ACT differs from that of a general mental
health case manager in that they are directly responsible for the provision
of a therapy or forms of therapy. In addition to undertaking the social
development and liaison work described earlier they are the primary therapist
within the care package and, instead of referring clinical problems
or responses to treatment on to other specialists, actually do this work
themselves. This will also extend to giving medication. Herein lies the
main difference between the two main types of case management: that
which sees the case manager as essentially a broker (social model), and
that which sees the case manager as a therapist (clinical model). The first
of these is derived from the original social role, the second resulting from
the general increase of nurses and health care workers within case management.
The assertive component may apply to either because it simply
denotes the intensity with which the contact between patient and case
manager is exerted. The case manager will undertake to maintain contact
with the patient no matter how resistive they are to such an approach, will
keep working at a problem no matter how difficult it is and continue to
support the patient irrespective of the opposition they may generate. The
whole purpose of this approach is to firstly maintain contact to ensure
that the patient is safe and secondly to uphold the integrity of the care
programme. Both of these serve to tell the patient that they are important,
have value as an individual and that the case manager is there for them
no matter what happens. Keeping a patient out of hospital is the aim of
such an approach, but only by giving that patient quality of life and dignity
within the community. Numerous controlled clinical trials of ACT
have been conducted with a wide range of people with severe mental illness,
including patients with schizophrenia, war veterans, dually diagnosed
patients and homeless people (Burns and Santos, 1995). These
studies report that patients spent less time in hospitals and more in independent
community housing. Their symptoms were reduced, their treatment
compliance was increased and ACT costs were usually lower (Dixon
et al., 1997; Mueser et al., 1998; Lehman et al., 1999). Furthermore, the
Programme of Assertive Community Treatment (PACT) is recognised by
the National Alliance of the Mentally Ill (NAMI) as the most effective
service delivery model for community treatment of severe mental illness.
As such, NAMI has launched a national grassroots effort called PACT
Across America to educate people about PACT and to offer training,
monitoring, certification and management services to those mental health
agencies wishing to implement the PACT model.