Community Ment Health J DOI 10.1007/s10597-014-9730-y
BRIEF REPORT
Can Small Intensive Case Management Teams be as Effective as Large Teams? Somaia Mohamed
Received: 13 February 2013 / Accepted: 28 April 2014 Ó Springer Science+Business Media New York (Outside the USA) 2014
Abstract In 2007, the Veterans Health Administration (VHA) implemented a program to deliver the full array of Assertive Community Treatment services in areas with low population density using teams with small staffs. VHA administrative data were used to compare treatment and outcomes of veterans who received services from teams with only two or three staff (N = 805) and veterans served by teams with ten or more staff (N = 861). After adjusting for baseline difference, smaller teams had statistically significantly less symptom improvement and smaller declines in suicidality indices but effect sizes were small and there were no differences on 11 other outcomes. These data demonstrate the clinical need, practical feasibility and potential effectiveness of providing intensive case management through small teams. Keywords Rural mental health Case management Access to care Community psychiatry Veterans issue Assertive community treatment (ACT) (Stein and Test 1980) is perhaps the most widely used evidence-based practice for providing community-based services to people with serious mental illnesses (individuals with mental illness which results in functional impairment (Kessler et al.
S. Mohamed New England Mental Illness, Research, Education and Clinical Center, West Haven, CT, USA S. Mohamed Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA S. Mohamed (&) VA Connecticut Health Care System, 950 Campbell Ave., West Haven, CT, USA e-mail: [email protected]
2001). There has been increasing concern in recent years about the availability of such services in more sparsely populated suburban and rural areas (NPFC 2005) with several studies showing substantially reduced access to and availability of this service in rural areas (McCarthy et al. 2009; Mohamed et al. 2009). There have been few reports of ACT implementation using programs with smaller staffs in less densely populated settings (Deci et al. 1994; Meyer and Morrissey 2007; Santos et al. 1993) and no published comparative studies of the performance of rural and urban teams. Since 1987, the Department of Veterans Affairs (VA) has developed a large national network of programs based on the ACT model to provide intensive community-based services to veterans with serious mental illness and high inpatient service use (Neale et al. 2007). The VA program, referred to as Mental Health Intensive Case Management (MHICM), currently operates at over 100 VA facilities and has been shown in a randomized trial to result in reduced hospital use and symptoms, and improve quality of life and client satisfaction (Rosenheck and Neale 1998). In 2004, the VA Strategic Mental Health Plan called for an intensive case management program for seriously mentally ill veterans in underserved rural areas. The first 20-sites of this initiative, named rural access networks for growth enhancement (RANGE) were implemented in fiscal year (FY) 2007. RANGE was followed by an additional series of 16 programs called (Enhanced RANGE or E-RANGE) that was implemented in 2009 and was intended to serve both severely mentally ill veterans and homeless veterans in rural areas. In this study we examine patient characteristics, patterns of service delivery and outcomes of veterans enrolled in these 42 small market intensive case management programs with 2–3 full-time equivalent employees (FTEEs)
123
Community Ment Health J
during FYs 2008–2011 and compare them with veterans enrolled in 12 large MHICM programs with 10 or more FTEE during the same years.
Methods Development and Implementation Strategies Clinicians participated in centrally lead monthly teleconference calls to guide day-to-day implementation, facilitate sharing of information and professional peer support. National training meetings were also held and individual training was provided when requested. Study Sample and Sources of Data The sample included all veterans enrolled in the 42 RANGE and E-RANGE programs in FY 2008–2011, both of which have 2–3 Full Time Employee Equivalent (FTEE) staff, (N = 805) and all veterans enrolled at sites with 10 or more FTEE participating in national evaluation of VA’s MHICM program during these years (N = 861). Especially large teams were chosen for this comparison to highlight differences in program staffing, the issue of central interest. Although data on urban versus rural residence of clients were not available, the vast majority of small programs are in cities and town of \50,000 and all are in cities of \150,000 while 10 of the 12 the largest MHICM teams are in areas with populations of more than 2 million people and all have populations of over 200,000. Administrative data documented sociodemographic characteristics, diagnoses, clinical status and community adjustment at the time of program entry on standardized intake forms. Data on patterns of service delivery were obtained from structured semi-annual clinical processes summaries completed by case managers on each veteran. Outcomes were assessed about 6 months after program entry with a structured assessment tool. Measures Clinical measures include the clinical diagnosis assigned by their treating clinician. The Brief Psychiatric Rating Scale (Overall and Gorham 1962) was completed by clinicians to measure symptom severity and the Brief Symptom Index (BSI) (Derogatis and Spencer 1992) to measure subjective distress. Selected questions from the Addiction Severity Index also administered by clinicians documented alcohol and drug use in the previous 30 days (McLellan et al. 1980). Community adjustment was evaluated using information on type of residence; global functioning as assessed by the Global Assessment of
123
Functioning (GAF) (Endicott et al. 1976); and selected items from the clinician administered Lehman Quality of Life Inventory (Lehman 1996) assessing satisfaction with life in general. Violent behavior in the past month was rated (Kulka et al. 1989) as was suicidality. To assess treatment processes during the first 6 months, case managers documented the frequency of face-to–contacts with the veteran in the community, distance from VA staff offices to the veteran’s home and travel time. The duration of contacts and case manager ratings of therapeutic alliance with the patient were also recorded. Therapeutic alliance was assessed with parallel case manager and client versions of seven 7-point Likert-type questions about the nature of the clinical relationship adapted from the Working Alliance Inventory (Horvath and Greenberg 1989) modified for use in these programs (Neale and Rosenheck 1995). Specific types of services that were provided during the 6 month period were also noted (e.g., rehabilitation, psychotherapy, crisis intervention, managing psychiatric medications, screening for medical problems, providing substance abuse treatment, housing and vocational support). Additionally, a structured outcome assessment was completed by case managers after 6 months of veteran participation in the program, allowing comparison of clinical change on the subset of participants who completed the follow-up assessment (small staff programs N = 655, 81 %; large staff programs N = 589, 69 %; v2 = 36.9, df = 1, p \ .001 The Institutional Review Board (IRB) of the VA Connecticut Healthcare system and Yale Medical School approved this study. All measures were administered in person and completed by clinicians in a paper and pencil format. Analysis First, we compare veterans in large and small programs on characteristics at the time of program entry. Stepwise logistic regression was used to identify a subset of characteristics that parsimoniously differentiated the two groups for use as covariates in outcome analyses. We then compared patterns of service delivery in the two types of programs using v2 tests using multiple regression analyses to control for differences in baseline characteristics. Analysis of Covariance was then used to compare 6-month changes in clinical outcomes between program types. Covariates identified by the stepwise logistic regression analyses mentioned above and the baseline values of each dependent variable were included as covariates. Because of the large sample size an alpha level of p \ .01 was used as the criterion of statistical significance. Effect sizes (ES) for outcomes were calculated as
Community Ment Health J
the difference in mean change divided by the pooled standard deviation of the measure at baseline.
Results Sociodemographic Characteristics Comparison of 805 veterans enrolled in small staff programs and 861 veterans enrolled in the large programs showed higher proportions of the veterans enrolled in the small programs were married or Caucasian and fewer were African American. A smaller proportion of the veterans enrolled in the small programs received a diagnosis of schizophrenia, although a greater proportion had co-occurring psychiatric and substance abuse diagnoses, affective disorders and PTSD and other anxiety disorders (data available on request). Psychiatric symptom severity on both the BPRS and the BSI were greater among small team clients as were the number of days of drug and alcohol use in the month preceding entry. Veterans enrolled in the small market programs also had significantly higher suicidality index scores. Small market clients spent more days living in independent housing than larger team clients and fewer days in restricted housing settings or homeless and were given higher GAF scores by their clinicians, but expressed less satisfaction with the quality if their lives on a general measure that summed items from several domains. Veterans enrolled in the small market programs also had significantly higher violence scores. Logistic Regression Stepwise logistic regression analysis identified eight characteristics that independently differentiated small and large teams, most notably showing veterans treated in small teams had more severe symptoms on two measures, an increased likelihood of being diagnosed with PTSD, Affective Disorder, dual diagnosis and having past criminal justice symptom involvement. Treatment Processes As expected veterans on rural and small market teams were more likely to live further away from the home base of their treatment team than MHICM veterans and it took case mangers longer to get to their homes. A somewhat greater proportion of small-team case managers spent more than an hour each week with their clients although slightly fewer saw their clients more than once per week reflecting longer visits by small teams. There was no difference in the frequency of contacts with veterans’ families. There was no significant difference on clinician- or client rated measures
of therapeutic alliance but a smaller proportion of smallteam veterans terminated their involvement in the program. Similar proportions of veterans served by small teams were reported to have received 6 of 11 specific clinical services, but they were less likely to receive social or recreational activities in the community, education/support to family or non-family caregivers, crisis intervention, management of psychiatric medications and screening or care for medical problems. Comparison of client change at 6 months between small and large teams (after adjusting for significant baseline differences and the baseline value of each outcome measure) revealed three significant differences in the amount of improvement out of 14 assessed outcomes. On both clinician rated symptoms and client subjective distress there was greater improvement among veterans treated by the larger teams, albeit with small ES (BSI: -7.25 for large teams vs. -3.54 for small teams, t = 4.19, p \ .001, ES = .18; BPRS: -6.46 for large teams vs. -3.07 for small teams, t = 4.92, p \ .001, ES = .25). On the suicidality index, too there was greater reduction (improvement) among veterans treated by the large teams -.35 for large teams versus -.22 for small teams, t = 2.87, p \ .005, ES = .12. These ES, range from .12 to .25, are at the lower range of small effects by the usual Cohen’s d standard of .20 for small effects, and thus are not likely to be clinically meaningful although they are not attributable to chance alone. There were no significant differences in the amount of change in measures of alcohol or drug use, employment, quality of life, days of incarceration, violent behavior, income, client- or case-manager rated therapeutic alliance, days of incarceration, or GAF scores.
Discussion This is the first study to directly compare small (2–3 staff members) and large (10 or more staff members) intensive psychiatric community care programs based on ACT principles. The data presented in this study illustrate both the practicability of implementing small ACT-like teams in small market area and their generally similar effectiveness to large teams. As expected veterans served by small teams in this study were more likely to live further away from the home base of their treatment team than veterans served by large teams and it took case mangers longer to travel to their homes. However, they reported greater duration of total contact with their case managers albeit with slightly less frequent contacts and no less contact in community settings, or with veterans’ families or community agencies. Significantly higher proportions of small-team veterans had more frequent contacts with case managers by phone
123
Community Ment Health J
or mail (presumably reflecting use of electronic communication which was specifically encouraged in this program), and less frequent contacts with non-family care givers, perhaps because they were less likely to live in restrictive housing settings supervised by non-family caregivers. Small-team case managers, however, reported slightly greater total time spent with veterans. It is notable that veterans on small teams did not score significantly differently on the client or case manager rated measure of therapeutic alliance than those treated on large teams, perhaps reflecting their positive response to efforts to reach out to them in their communities where there are generally less services. Perhaps most notable is that there were no significant differences in the amount of improvement on all but three outcomes. Veterans treated by small teams showed statistically less improvement on two symptom measures and on an index of suicidality although the ES of these differences were small (.12–.25) suggesting that they may not be clinically meaningful even though they were not due to chance alone. These differences may also reflect the lower termination rate, and higher follow-up rates achieved by the small teams as veterans who were doing poorly on large teams could have more easily transferred to other programs nearby, thus artificially improving their 6-month outcomes. Strengths of this study are the relatively large sample sizes and that it is the first to directly compare small and large programs that are governed by the same health care system. Several limitations also deserve comment. Since our design was not a randomized controlled trial of clients assigned to small and large teams our conclusions about relative program effectiveness must remain tentative. There were also clear baseline differences between the groups and although we adjusted for these differences using multiple regression methods, there may have been unmeasured factors that influence the outcomes along with the significant difference in follow up assessment rates. There were also significantly greater termination rates and lower follow-up rates among clients treated by the large teams which may have biased the results in their favor. Despite these limitations, this study demonstrates the clinical need, practical feasibility and potential effectiveness of providing intensive case management through small specialized teams in small market areas.
References Deci, P. A., Santos, A. B., McLeod-Bryant, S., & Deas-Nesmith, D. (1994). MUSC’s rural mental health services initiatives. The
123
Journal of the South Carolina Medical Association, 90(3), 101–104. Derogatis, L. R., & Spencer, N. (1992). The brief symptom index; administration, scoring and procedure manual. Baltimore, MD: Johns Hopkins. Endicott, J., Spitzer, R. L., Fleiss, J. L., & Cohen, J. (1976). The global assessment scale. A procedure for measuring overall severity of psychiatric disturbance. Archives of General Psychiatry, 33(6), 766–771. Horvath, A. O., & Greenberg, L. S. (1989). The development and validation of the Working Alliance Inventory. Journal of Counseling Psychology, 36, 223–233. Kessler, R. C., Berglund, P. A., Bruce, M. L., Koch, J. R., Laska, E. M., Leaf, P. J., et al. (2001). The prevalence and correlates of untreated serious mental illness. Health Services Research, 36(6 Pt 1), 987–1007. Kulka, R. A., Schlenger, W. E., & Fairbank, J. A. (1989). Trauma and the Vietnam war generation: Report of findings from the National Vietnam Veterans Readjustment Study. New York: Brunner/Mazel. Lehman, A. F. (1996). Measures of quality of life among persons with severe and persistent mental disorders. Social Psychiatry and Psychiatric Epidemiology, 31(2), 78–88. McCarthy, J. F., Valenstein, M., Dixon, L., Visnic, S., Blow, F. C., & Slade, E. (2009). Initiation of assertive community treatment among veterans with serious mental illness: Client and program factors. Psychiatric Services, 60(2), 196–201. doi:10.1176/appi. ps.60.2.196. McLellan, A. T., Luborsky, L., Woody, G. E., & O’Brien, C. P. (1980). An improved diagnostic evaluation instrument for substance abuse patients. The Addiction Severity Index. The Journal of Nervous and Mental Disease, 168(1), 26–33. Meyer, P. S., & Morrissey, J. P. (2007). A comparison of assertive community treatment and intensive case management for patients in rural areas. Psychiatric Services, 58(1), 121–127. doi:10.1176/appi.ps.58.1.121-a. Mohamed, S., Neale, M., & Rosenheck, R. A. (2009). VA intensive mental health case management in urban and rural areas: Veteran characteristics and service delivery. Psychiatric Services, 60(7), 914–921. doi:10.1176/appi.ps.60.7.914. Neale, M. S., & Rosenheck, R. A. (1995). Therapeutic alliance and outcome in a VA intensive case management program. Psychiatric Services, 46(7), 719–721. Neale, M., Rosenheck, R., Castrodonatti, J., Martin, A., Morrissey, J., & D’amico, M. (2007). Mental Health Intensive Case Management (MHICM): The Tenth National Performance Monitoring Report: FY 2006. West Haven, CT: Northeast Program Evaluation Center. NPFC. (2005). Interim report of the president’s new freedom commission on mental health: 2002. Overall, J., & Gorham, D. (1962). Brief Psychiatric Rating Scale. Psychological Reports, 10, 799–812. Rosenheck, R. A., & Neale, M. S. (1998). Cost-effectiveness of intensive psychiatric community care for high users of inpatient services. Archives of General Psychiatry, 55(5), 459–466. Santos, A. B., Deci, P. A., Lachance, K. R., Dias, J. K., Sloop, T. B., Hiers, T. G., et al. (1993). Providing assertive community treatment for severely mentally ill patients in a rural area. Hospital and Community Psychiatry, 44(1), 34–39. Stein, L. I., & Test, M. A. (1980). Alternative to mental hospital treatment. I. Conceptual model, treatment program, and clinical evaluation. Archives of General Psychiatry, 37(4), 392–397.
BRIEF REPORT
Can Small Intensive Case Management Teams be as Effective as Large Teams? Somaia Mohamed
Received: 13 February 2013 / Accepted: 28 April 2014 Ó Springer Science+Business Media New York (Outside the USA) 2014
Abstract In 2007, the Veterans Health Administration (VHA) implemented a program to deliver the full array of Assertive Community Treatment services in areas with low population density using teams with small staffs. VHA administrative data were used to compare treatment and outcomes of veterans who received services from teams with only two or three staff (N = 805) and veterans served by teams with ten or more staff (N = 861). After adjusting for baseline difference, smaller teams had statistically significantly less symptom improvement and smaller declines in suicidality indices but effect sizes were small and there were no differences on 11 other outcomes. These data demonstrate the clinical need, practical feasibility and potential effectiveness of providing intensive case management through small teams. Keywords Rural mental health Case management Access to care Community psychiatry Veterans issue Assertive community treatment (ACT) (Stein and Test 1980) is perhaps the most widely used evidence-based practice for providing community-based services to people with serious mental illnesses (individuals with mental illness which results in functional impairment (Kessler et al.
S. Mohamed New England Mental Illness, Research, Education and Clinical Center, West Haven, CT, USA S. Mohamed Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA S. Mohamed (&) VA Connecticut Health Care System, 950 Campbell Ave., West Haven, CT, USA e-mail: [email protected]
2001). There has been increasing concern in recent years about the availability of such services in more sparsely populated suburban and rural areas (NPFC 2005) with several studies showing substantially reduced access to and availability of this service in rural areas (McCarthy et al. 2009; Mohamed et al. 2009). There have been few reports of ACT implementation using programs with smaller staffs in less densely populated settings (Deci et al. 1994; Meyer and Morrissey 2007; Santos et al. 1993) and no published comparative studies of the performance of rural and urban teams. Since 1987, the Department of Veterans Affairs (VA) has developed a large national network of programs based on the ACT model to provide intensive community-based services to veterans with serious mental illness and high inpatient service use (Neale et al. 2007). The VA program, referred to as Mental Health Intensive Case Management (MHICM), currently operates at over 100 VA facilities and has been shown in a randomized trial to result in reduced hospital use and symptoms, and improve quality of life and client satisfaction (Rosenheck and Neale 1998). In 2004, the VA Strategic Mental Health Plan called for an intensive case management program for seriously mentally ill veterans in underserved rural areas. The first 20-sites of this initiative, named rural access networks for growth enhancement (RANGE) were implemented in fiscal year (FY) 2007. RANGE was followed by an additional series of 16 programs called (Enhanced RANGE or E-RANGE) that was implemented in 2009 and was intended to serve both severely mentally ill veterans and homeless veterans in rural areas. In this study we examine patient characteristics, patterns of service delivery and outcomes of veterans enrolled in these 42 small market intensive case management programs with 2–3 full-time equivalent employees (FTEEs)
123
Community Ment Health J
during FYs 2008–2011 and compare them with veterans enrolled in 12 large MHICM programs with 10 or more FTEE during the same years.
Methods Development and Implementation Strategies Clinicians participated in centrally lead monthly teleconference calls to guide day-to-day implementation, facilitate sharing of information and professional peer support. National training meetings were also held and individual training was provided when requested. Study Sample and Sources of Data The sample included all veterans enrolled in the 42 RANGE and E-RANGE programs in FY 2008–2011, both of which have 2–3 Full Time Employee Equivalent (FTEE) staff, (N = 805) and all veterans enrolled at sites with 10 or more FTEE participating in national evaluation of VA’s MHICM program during these years (N = 861). Especially large teams were chosen for this comparison to highlight differences in program staffing, the issue of central interest. Although data on urban versus rural residence of clients were not available, the vast majority of small programs are in cities and town of \50,000 and all are in cities of \150,000 while 10 of the 12 the largest MHICM teams are in areas with populations of more than 2 million people and all have populations of over 200,000. Administrative data documented sociodemographic characteristics, diagnoses, clinical status and community adjustment at the time of program entry on standardized intake forms. Data on patterns of service delivery were obtained from structured semi-annual clinical processes summaries completed by case managers on each veteran. Outcomes were assessed about 6 months after program entry with a structured assessment tool. Measures Clinical measures include the clinical diagnosis assigned by their treating clinician. The Brief Psychiatric Rating Scale (Overall and Gorham 1962) was completed by clinicians to measure symptom severity and the Brief Symptom Index (BSI) (Derogatis and Spencer 1992) to measure subjective distress. Selected questions from the Addiction Severity Index also administered by clinicians documented alcohol and drug use in the previous 30 days (McLellan et al. 1980). Community adjustment was evaluated using information on type of residence; global functioning as assessed by the Global Assessment of
123
Functioning (GAF) (Endicott et al. 1976); and selected items from the clinician administered Lehman Quality of Life Inventory (Lehman 1996) assessing satisfaction with life in general. Violent behavior in the past month was rated (Kulka et al. 1989) as was suicidality. To assess treatment processes during the first 6 months, case managers documented the frequency of face-to–contacts with the veteran in the community, distance from VA staff offices to the veteran’s home and travel time. The duration of contacts and case manager ratings of therapeutic alliance with the patient were also recorded. Therapeutic alliance was assessed with parallel case manager and client versions of seven 7-point Likert-type questions about the nature of the clinical relationship adapted from the Working Alliance Inventory (Horvath and Greenberg 1989) modified for use in these programs (Neale and Rosenheck 1995). Specific types of services that were provided during the 6 month period were also noted (e.g., rehabilitation, psychotherapy, crisis intervention, managing psychiatric medications, screening for medical problems, providing substance abuse treatment, housing and vocational support). Additionally, a structured outcome assessment was completed by case managers after 6 months of veteran participation in the program, allowing comparison of clinical change on the subset of participants who completed the follow-up assessment (small staff programs N = 655, 81 %; large staff programs N = 589, 69 %; v2 = 36.9, df = 1, p \ .001 The Institutional Review Board (IRB) of the VA Connecticut Healthcare system and Yale Medical School approved this study. All measures were administered in person and completed by clinicians in a paper and pencil format. Analysis First, we compare veterans in large and small programs on characteristics at the time of program entry. Stepwise logistic regression was used to identify a subset of characteristics that parsimoniously differentiated the two groups for use as covariates in outcome analyses. We then compared patterns of service delivery in the two types of programs using v2 tests using multiple regression analyses to control for differences in baseline characteristics. Analysis of Covariance was then used to compare 6-month changes in clinical outcomes between program types. Covariates identified by the stepwise logistic regression analyses mentioned above and the baseline values of each dependent variable were included as covariates. Because of the large sample size an alpha level of p \ .01 was used as the criterion of statistical significance. Effect sizes (ES) for outcomes were calculated as
Community Ment Health J
the difference in mean change divided by the pooled standard deviation of the measure at baseline.
Results Sociodemographic Characteristics Comparison of 805 veterans enrolled in small staff programs and 861 veterans enrolled in the large programs showed higher proportions of the veterans enrolled in the small programs were married or Caucasian and fewer were African American. A smaller proportion of the veterans enrolled in the small programs received a diagnosis of schizophrenia, although a greater proportion had co-occurring psychiatric and substance abuse diagnoses, affective disorders and PTSD and other anxiety disorders (data available on request). Psychiatric symptom severity on both the BPRS and the BSI were greater among small team clients as were the number of days of drug and alcohol use in the month preceding entry. Veterans enrolled in the small market programs also had significantly higher suicidality index scores. Small market clients spent more days living in independent housing than larger team clients and fewer days in restricted housing settings or homeless and were given higher GAF scores by their clinicians, but expressed less satisfaction with the quality if their lives on a general measure that summed items from several domains. Veterans enrolled in the small market programs also had significantly higher violence scores. Logistic Regression Stepwise logistic regression analysis identified eight characteristics that independently differentiated small and large teams, most notably showing veterans treated in small teams had more severe symptoms on two measures, an increased likelihood of being diagnosed with PTSD, Affective Disorder, dual diagnosis and having past criminal justice symptom involvement. Treatment Processes As expected veterans on rural and small market teams were more likely to live further away from the home base of their treatment team than MHICM veterans and it took case mangers longer to get to their homes. A somewhat greater proportion of small-team case managers spent more than an hour each week with their clients although slightly fewer saw their clients more than once per week reflecting longer visits by small teams. There was no difference in the frequency of contacts with veterans’ families. There was no significant difference on clinician- or client rated measures
of therapeutic alliance but a smaller proportion of smallteam veterans terminated their involvement in the program. Similar proportions of veterans served by small teams were reported to have received 6 of 11 specific clinical services, but they were less likely to receive social or recreational activities in the community, education/support to family or non-family caregivers, crisis intervention, management of psychiatric medications and screening or care for medical problems. Comparison of client change at 6 months between small and large teams (after adjusting for significant baseline differences and the baseline value of each outcome measure) revealed three significant differences in the amount of improvement out of 14 assessed outcomes. On both clinician rated symptoms and client subjective distress there was greater improvement among veterans treated by the larger teams, albeit with small ES (BSI: -7.25 for large teams vs. -3.54 for small teams, t = 4.19, p \ .001, ES = .18; BPRS: -6.46 for large teams vs. -3.07 for small teams, t = 4.92, p \ .001, ES = .25). On the suicidality index, too there was greater reduction (improvement) among veterans treated by the large teams -.35 for large teams versus -.22 for small teams, t = 2.87, p \ .005, ES = .12. These ES, range from .12 to .25, are at the lower range of small effects by the usual Cohen’s d standard of .20 for small effects, and thus are not likely to be clinically meaningful although they are not attributable to chance alone. There were no significant differences in the amount of change in measures of alcohol or drug use, employment, quality of life, days of incarceration, violent behavior, income, client- or case-manager rated therapeutic alliance, days of incarceration, or GAF scores.
Discussion This is the first study to directly compare small (2–3 staff members) and large (10 or more staff members) intensive psychiatric community care programs based on ACT principles. The data presented in this study illustrate both the practicability of implementing small ACT-like teams in small market area and their generally similar effectiveness to large teams. As expected veterans served by small teams in this study were more likely to live further away from the home base of their treatment team than veterans served by large teams and it took case mangers longer to travel to their homes. However, they reported greater duration of total contact with their case managers albeit with slightly less frequent contacts and no less contact in community settings, or with veterans’ families or community agencies. Significantly higher proportions of small-team veterans had more frequent contacts with case managers by phone
123
Community Ment Health J
or mail (presumably reflecting use of electronic communication which was specifically encouraged in this program), and less frequent contacts with non-family care givers, perhaps because they were less likely to live in restrictive housing settings supervised by non-family caregivers. Small-team case managers, however, reported slightly greater total time spent with veterans. It is notable that veterans on small teams did not score significantly differently on the client or case manager rated measure of therapeutic alliance than those treated on large teams, perhaps reflecting their positive response to efforts to reach out to them in their communities where there are generally less services. Perhaps most notable is that there were no significant differences in the amount of improvement on all but three outcomes. Veterans treated by small teams showed statistically less improvement on two symptom measures and on an index of suicidality although the ES of these differences were small (.12–.25) suggesting that they may not be clinically meaningful even though they were not due to chance alone. These differences may also reflect the lower termination rate, and higher follow-up rates achieved by the small teams as veterans who were doing poorly on large teams could have more easily transferred to other programs nearby, thus artificially improving their 6-month outcomes. Strengths of this study are the relatively large sample sizes and that it is the first to directly compare small and large programs that are governed by the same health care system. Several limitations also deserve comment. Since our design was not a randomized controlled trial of clients assigned to small and large teams our conclusions about relative program effectiveness must remain tentative. There were also clear baseline differences between the groups and although we adjusted for these differences using multiple regression methods, there may have been unmeasured factors that influence the outcomes along with the significant difference in follow up assessment rates. There were also significantly greater termination rates and lower follow-up rates among clients treated by the large teams which may have biased the results in their favor. Despite these limitations, this study demonstrates the clinical need, practical feasibility and potential effectiveness of providing intensive case management through small specialized teams in small market areas.
References Deci, P. A., Santos, A. B., McLeod-Bryant, S., & Deas-Nesmith, D. (1994). MUSC’s rural mental health services initiatives. The
123
Journal of the South Carolina Medical Association, 90(3), 101–104. Derogatis, L. R., & Spencer, N. (1992). The brief symptom index; administration, scoring and procedure manual. Baltimore, MD: Johns Hopkins. Endicott, J., Spitzer, R. L., Fleiss, J. L., & Cohen, J. (1976). The global assessment scale. A procedure for measuring overall severity of psychiatric disturbance. Archives of General Psychiatry, 33(6), 766–771. Horvath, A. O., & Greenberg, L. S. (1989). The development and validation of the Working Alliance Inventory. Journal of Counseling Psychology, 36, 223–233. Kessler, R. C., Berglund, P. A., Bruce, M. L., Koch, J. R., Laska, E. M., Leaf, P. J., et al. (2001). The prevalence and correlates of untreated serious mental illness. Health Services Research, 36(6 Pt 1), 987–1007. Kulka, R. A., Schlenger, W. E., & Fairbank, J. A. (1989). Trauma and the Vietnam war generation: Report of findings from the National Vietnam Veterans Readjustment Study. New York: Brunner/Mazel. Lehman, A. F. (1996). Measures of quality of life among persons with severe and persistent mental disorders. Social Psychiatry and Psychiatric Epidemiology, 31(2), 78–88. McCarthy, J. F., Valenstein, M., Dixon, L., Visnic, S., Blow, F. C., & Slade, E. (2009). Initiation of assertive community treatment among veterans with serious mental illness: Client and program factors. Psychiatric Services, 60(2), 196–201. doi:10.1176/appi. ps.60.2.196. McLellan, A. T., Luborsky, L., Woody, G. E., & O’Brien, C. P. (1980). An improved diagnostic evaluation instrument for substance abuse patients. The Addiction Severity Index. The Journal of Nervous and Mental Disease, 168(1), 26–33. Meyer, P. S., & Morrissey, J. P. (2007). A comparison of assertive community treatment and intensive case management for patients in rural areas. Psychiatric Services, 58(1), 121–127. doi:10.1176/appi.ps.58.1.121-a. Mohamed, S., Neale, M., & Rosenheck, R. A. (2009). VA intensive mental health case management in urban and rural areas: Veteran characteristics and service delivery. Psychiatric Services, 60(7), 914–921. doi:10.1176/appi.ps.60.7.914. Neale, M. S., & Rosenheck, R. A. (1995). Therapeutic alliance and outcome in a VA intensive case management program. Psychiatric Services, 46(7), 719–721. Neale, M., Rosenheck, R., Castrodonatti, J., Martin, A., Morrissey, J., & D’amico, M. (2007). Mental Health Intensive Case Management (MHICM): The Tenth National Performance Monitoring Report: FY 2006. West Haven, CT: Northeast Program Evaluation Center. NPFC. (2005). Interim report of the president’s new freedom commission on mental health: 2002. Overall, J., & Gorham, D. (1962). Brief Psychiatric Rating Scale. Psychological Reports, 10, 799–812. Rosenheck, R. A., & Neale, M. S. (1998). Cost-effectiveness of intensive psychiatric community care for high users of inpatient services. Archives of General Psychiatry, 55(5), 459–466. Santos, A. B., Deci, P. A., Lachance, K. R., Dias, J. K., Sloop, T. B., Hiers, T. G., et al. (1993). Providing assertive community treatment for severely mentally ill patients in a rural area. Hospital and Community Psychiatry, 44(1), 34–39. Stein, L. I., & Test, M. A. (1980). Alternative to mental hospital treatment. I. Conceptual model, treatment program, and clinical evaluation. Archives of General Psychiatry, 37(4), 392–397.
