Mental Health Nursing

Case management: perspectives of the UK and US systems 103
a care system or approach from one health care culture to another. These
centre on the fact that care systems are usually organised differently and
people have separate outcome expectations. In the UK the seriously
mentally ill are a small group of individuals, defined by their regular use
of care services and their consistent inability to cope, over time, with
genuine independent living. So, too, case management services can be
organised in several ways, but the usual configuration in the UK is for
separate case management facilities to be added to existing, traditional
community mental health teams, either as a discrete team in its own right or
as additional team members. Ideally, health and social services should
jointly fund them, although this has been slow to develop and currently
most UK case management comes under the auspices of health care, though
with health care reforms this is changing.
Clients are referred for case management for different reasons but
usually because they are resistive to the approaches of traditionally organised
community mental health nurses (CPNs), suspicious of what they see as
punitive care from State-controlled mental health services (Ward et al.,
2000), deemed to be at risk of falling through the net of existing service
provision, or are in need of complex care for diverse long-term mental
health problems (Renshaw, 1988). A case manager who may adopt various
methods of meeting client needs handles recommended caseloads of
up to 15 clients. Two reviews undertaken by one of the authors (Armstrong
and Ward, 1966; Ward et al., 1999) show that very often UK case managers
tend to adopt an approach to care dictated by their previous professional
occupation. As over 90% of managers are from a mental health
nursing background, their work tends to be primary contact and therapeutic
in nature (clinical model), but others, such as those with a social work
background, are more likely to use a brokerage approach (social model).
However, research has also shown that many UK case managers use a
combination of both models, adopting the practical work described above
in the ‘nursing role within case management’ section as well as the treatment
and therapy activities described in the ‘assertive community treatment’
(ACT) section.
Services provided by case managers in the UK are difficult to define
because they are very much dependent upon the needs of the client. However,
a broad spectrum of possibilities exist, including therapeutic befriending,
support with activities of daily living, personal and social skills development,
housing, State benefits, financial support, and recreational and
social care. Within the UK system there is a recognition that clients admitted
onto a case manager’s caseload will remain there for a considerable
period of time, if not indefinitely (Ward et al., 1999). The purpose of
case management is to support individuals within the community, to enable