Community Mental Health Journal, Vol. 28, No. 6, December 1992
N e e d s A s s e s s m e n t for P e r s o n s with Severe Mental Illness: What Services Are N e e d e d for Successful C o m m u n i t y l Jiving? Janet Ford, Ph.D. Dale Young, MSW Barbara C. Pere~ MA Robert L Obermeyer Donald G. Rohner
A B S T R A C T : The development and i m p l e m e n t a t i o n of effective c o m m u n i t y support systems are goals of m a n y public m e n t a l h e a l t h a u t h o r i t i e s who are a t t e m p t i n g to shift t h e focus and dollars for m e n t a l h e a l t h services from i n p a t i e n t to c o m m u n i t y care. This article p r e s e n t s the r e s u l t s of a survey which a s k e d 90 c o m m u n i t y m e n t a l h e a l t h agency case m a n a g e r s to assess t h e c o m m u n i t y support and r e s i d e n t i a l needs of over 1400 of t h e i r clients. Medication m o n i t o r i n g and t h e r a p y were r a t e d h i g h p r i o r i t y needs. Psychosocial t r e a t m e n t , day a n d vocational activities also r a n k e d high. S u r v e y responses r e g a r d i n g r e s i d e n t i a l services i n d i c a t e d a need for more supported a n d supervised options.
INTROD UCTION In the past three decades, the public mental health system nationally has experienced a decrease in the utilization of state mental hospitals and a concomitant shift to the community of responsibility to provide The study reported was a collaborative effort by county and agency staff. Requests for reprints should be directed to Dr. Ford, Director of Special Research Projects, Hamilton County Community Mental Health Board, 801A W. 8th St., Suite 500, Cincinnati, OH 452O3. 491
9 1992 Human Sciences Press, Inc.
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services to persons with severe and chronic mental illness (U.S. Bureau of the Census, 1985). Like most of the nation, Hamilton County, Ohio, has experienced a gradual decrease in state psychiatric hospital beds. The transition of many long-term state hospital residents into the community and the shorter lengths of stay for more recent admissions have increased demands both on existing housing resources and for new services to accommodate community clients with more intensive needs. Unlike many areas, Hamilton County has had state support, bolstered by funds from the Robert Wood Johnson Foundation, for its efforts to identify the needs of persons with severe mental illness and to develop community services to address them. In terms of its state mental health system, Ohio has been considered one of the leaders in the national effort to shift resources and services for persons with serious mental illness from inpatient to community settings. Torrey's 1990 rating of state programs for the seriously mentally ill ranked Ohio fourth overall in terms of services and first for states with over 6 million residents (Torrey, Wolfe, & Flynn, 1990). During the decade of the 1980s, the Ohio Department of Mental Health provided strong leadership to county mental health boards to adopt and operationalize the concept of a community support system (CSS) and encouraged implementation of the CSS model throughout the state. The basis of the CSS model is the establishment of an array of services including outreach, housing, emergency/crisis response, medication, vocational, and other services to meet the needs of individual clients. Case management serves as the focal point of service provision, helping to ensure that clients receive the services they need by providing coordination of and linkage to services, and assessing the continuing appropriateness of services as the needs of the clients change (Stroul, 1988). The strong commitment by the state to the CSS model in general and case management in particular has been reflected in the Ohio Department of Mental Health's efforts to secure a strong funding base, mandate the development of the necessary components for case management to work, and support programs to increase the human resource capacity to deliver needed services to the mentally ill (Knisley, 1987). A case management system funded and administered through the Hamilton County Mental Health Board has been in operation since 1986. Since that time, services have expanded from approximately 1800 clients served by 45 case managers in 6 agencies to approximately 3500 clients served by 93 case managers in 8 agencies.
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BA CKGR 0 UND In this context, with three years of system experience and the anticipation that the further reduction in hospital census would allow for the transfer of funds from inpatient to community services, it was decided to conduct a county-wide needs assessment to identify needs for expanded and additional community services. A great deal of the responsibility for the successful development and implementation of a community support system for persons with severe mental illness rests on the shoulders of the system case managers. The survey attempted to capitalize on the knowledge and experiences of those service providers who have the most extensive awareness of clients' lives in the community. A review of the literature indicates that few needs assessments have been conducted in the area of CSS implementation; fewer have been conducted using experienced case managers as the respondents. Stroul (1988) notes that clear progress has been made in the implementation of CSS on a national level but there still remains much to be done. Lack of safe and affordable housing, weak or non-existent accountability and leadership, the need for additional community supports, and the general lack of resources are cited as problems. Test (1981) identified residential services, assistance in meeting basic needs, crisis intervention services, somatic therapies, and comprehensive psychosocial treatment as necessary for clients to achieve the goals of community based treatment. Landsberg, Fletcher, and Maxwell (1987) conducted a needs assessment to determine what services were needed for dually diagnosed mentally ill and mentally retarded clients to succeed in a rural New York community. The results indicated that more specialized residential beds, increased mental health clinical services, specialized day treatment programs, inpatient psychiatric care and case management resources were needed by these clients. Solomon and Davis (1985) asked inpatient social workers to assess the community service needs of psychiatric patients being discharged to the community. The social workers identified chemotherapy and individual counseling as the most needed services by the study cohort. In a followup study (Solomon, Beck, & Gordon, 1988), perspectives of patients, families, and mental health practitioners were compared in regard to what patients needed to succeed in the community. Patients focused on the needs for help finding a job, aftercare services, and finding a place to live. Family members thought clients would need assistance in those areas as well as in managing money, taking medications, and perform-
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ing household chores. Mental health service providers saw the clients as needing assistance in even more areas, including engaging in leisure activities. Family members and service providers were more likely t h a n patients to identify a need for supervised housing. Lynch and Kruzich (1986) focused on the needs of the chronically mentally ill from both mental health practitioner and client perspectives. Mental health professionals identified medication checks, individual therapy, and episodic case m a n a g e m e n t as the most needed services. Client resistance was cited as the major barrier to service provision. Client respondents identified activities programs, daily living skills, and evening and weekend services as most needed services, with financial problems and unavailability of services being the major barriers to obtaining services. State support for the CSS model has promoted expansion of case m a n a g e m e n t and other community services, but has not eliminated the need to assess and prioritize the needs of the mentally ill population in order to allocate resources to best serve this population in the community. The literature review cited the need for housing and residential services, financial assistance, and more outpatient and support services for persons with mental illness living in the community. All of these areas have been addressed with expanded resources in the Hamilton County community mental health service system. Have the extensive efforts to expand the array of housing options and support services been successful in meeting the clients' community needs? What needs are not being met? What other services may be needed for clients to be able to remain in the community? This report presents the results of a survey of ninety community mental health agency case managers regarding the service needs of over one thousand of their clients. The system-wide survey was conducted to determine what services in addition to case management are most needed by clients to establish and sustain quality of life in the community. The survey instrument and survey methodology were the products of a collaborative effort on the part of case management supervisors, case management directors, and Mental Health Board staff.
METHODOLOGY As administered through the Hamilton County CommunityMental Health Board, case management services are provided by 17 treatment teams at 8 contract community mental health agencies.Each treatment team is made up of 4-7 case managers with a
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full-time supervisor and a half-time psychiatrist assigned to each team. The treatment teams provide 24 hour a day crisis intervention to their clients and offer a clientcentered, holistic approach to treatment which focuses on client strengths, life planning, use of natural community resources, family and systems collaboration, and service in the client as opposed to agency environment. Case management is offered to all clients who meet the Ohio Department of Mental Health criteria for severe mental disability. The system-wide administration of the program limits the extent to which individual agencies can vary from the state model of case management service provision.
Sampling Case managers were asked to assess the needs of 1706 randomly selected clients, a sample which included approximately half of the current case management caseload. Current cases were defined as clients who had a contact with the case manager within the 90 days prior to the date of the sample selection. Every other client on each agency's current caseload list was selected for inclusion in the study sample, so the proportion of the sample cases from each case management agency and team was representative of the actual caseload. Case managers and their supervisors collaborated on the identification/definition of each client's needs for completion of each survey form. This approach was employed in part to ensure consistent interpretation of survey items, and also because it is consistent with the team approach employed in each participating agency.
Survey Design The first section of the survey was designed to elicit case managers' perceptions of the support or assistance in addition to case management required by each sample client in order for that client to remain in the community. Areas of need listed included daily activities, household maintenance, and mental/physical health care. Respondents were asked to estimate the frequency, intensity and duration of assistance needed in each identified area of need. Frequency responses ranged from ~daily" to ~once a month or less frequent." Intensity of assistance ranged from slight, i.e., '~minor verbal assistance" to great, %xtensive face-to-face assistance." Estimated duration of need for assistance ranged from less than 90 days to more than 2 years. The second section of the survey focused on recommendations for housing/residential options, again giving a list of options from client's ~own home" to ~long-term psychiatric hospital." Specific instructions were given to respondents for completion of each item during a training session conducted by the Mental Health Board's coordinator of case management services. These instructions included the following. For Section I: 1. Need for assistance in an area is indicated if the client has additional needs that currently are not being met by case management or other support services. 2. Clients are to be assessed in relation to baseline or usual functioning, recognizing that clients may be either in crisis or in an unusually stable state at the time of the survey. 3. Clients are to be assessed according to their own standards of need, not according to the case managers' standards. For example, the client and the case manager may have different standards regarding personal hygiene, housekeeping, socialization, and so on. 4. Need areas are to be assessed in terms of life in the community, not in terms of client's functioning at the mental health agency.
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For Section II, case managers were told to give their opinion of the type of housing needed by each client, then to indicate whether the client would accept that option. Responses were to be based on the case management team's knowledge of the client; clients were specifically questioned when the respondents felt unable to respond to a particular item. Ninety case managers and 17 case management supervisors participated in completing the surveys. A return rate of 86.2% was achieved; 1470 surveys were completed.
Demographic Information The 1470 clients assessed for this study were demographically representative of the total case management client population. Gender: 53% female and 47% male. Race: 40% black, 59% white, and 1% listed as "other." Age was categorized as follows: (1) 1825 years old: 6.3%, (2) 26-35 years old: 30.5%, (3) 36-50 years old: 36.1%, (4) 51-65: 21.2%, and (5) over 65 years old 5.5%. Date of admission to case management services: 35% of the sample cases had been admitted to case management services fewer than 6 months prior to the sample selection date; 36% had been receiving case management services for 6-12 months; 29% had been in their program for more than 1 year. As stated previously, all of the clients had been in direct contact with a case manager either face-to-face or by telephone within the 90 days prior to the sample selection.
SUMMARY OF FINDINGS FOR THE OVERALL GROUP Areas of Assistance Needed The needs identified most frequently by the respondents were: (1) psychotropic medication monitoring, (2) setting limits on behavior, (3) socialization, (4) keeping appointments (with any service), and (5) household budgeting/money management. Over 40% of the sample clients were assessed as needing additional assistance in each of these areas. Estimated frequency of assistance needed varied by areas but skewed toward "weekly" or "daily" assistance. Estimated intensity of assistance needed also skewed toward the more intense end of the scale, with over 75% of clients needing more than minor verbal assistance in their areas of need. For those clients who were reported as being ~in need," the anticipated duration of assistance was long term, with over 50% estimated to need assistance for more than two years.
Optimal Living Arrangements Respondents then were asked to indicate what housing/residential options they, as case managers, thought were needed by each client, and what options they believed the client would accept. The results indicated that case managers perceived there were some differences
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between their assessments and those of their clients in regard to optimal housing options. The most frequently chosen options in response to what clients needed were: own home (31.3%), and family home (16.5%). Two hundred and nineteen clients (15%) were identified as needing some type of structured residential program, most frequently group homes (53 responses) or highly structured residential programs (43 responses). The most frequent responses to what housing/residential option case managers believed the client would accept also were own home (40%) and family home (21%). As shown in the Table, the numbers of clients identified as wanting to live in these residential options were higher than the numbers of clients identified as needing to live in them. In general, the case manager respondents indicated that more clients needed structured residential settings than were willing to accept them. Halfway houses and other transitional residential options were not among the most preferred housing options. Responses estimating duration of need for the recommended housing/residential option were skewed toward long term with over 85% of the sample clients reported to need their housing option for more than 2 years, and 11% needed housing options for 6 m o n t h s - 2 years.
Additional Supports Needed Responses to an open-ended question asking what clients needed in addition to case m a n a g e m e n t and/or residential support to remain in the community were grouped into categories. The five categories with the greatest number of responses were: day program (158 responses); substance abuse treatment (122); medication monitoring (99); therapy/ specialized counseling (96); and vocational training (94).
S U R V E Y R E S U L T S B Y SPECIAL CLIENT GROUPS In order to determine whether there were differences in the assessments of client needs according to selected client characteristics, the results of the survey were grouped by client gender, race, age group, and date of admission.
Gender Chi square tests revealed that significantly more male clients were assessed as needing assistance in all of the areas listed except for "accessing transportation" and "caring for, coping with physical/medical conditions."
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TABLE 1 H o u s i n g / R e s i d e n t i a l Options: Case M a n a g e r A s s e s s m e n t s of Client N e e d s vs. Client Choice Case Manager Assessed Client Need Residential Option
1] Own Home 2] Family Home 3] M.H. Subsidized Independent Living Apartment (alone or with others); C.M. support only 4] M.H. Subsidized Independent Living Apartment; supervision (in addition to C.M.) needed 5] M.H. Subsidized Independent Living Apartment; support (in addition to C.M.) needed 6] Community Mental Health Homes; primary need for room and board 7] Community Mental Health Homes; special needs: medical problems 8] Community Mental Health Homes; special needs: additional supervision/ high risk 9] Single Room Occupancy 10] Halfway House 11] Group Home 12] Minimally Structured Residential Program 13] Highly Structured Residential Program 14] Residential Program for SA/MI* 15] Residential Program for MR/MI** 16] Residential Program for Young, Chronically Mentally Ill Adults 17] Nursing Home 18] Long Term Psychiatric Hospital 19] Other No response (misc.) Total sample *SA/MI = Substance Abuser and Mentally Ill **MR/MI = Mentally Retarded and Mentally Ill
Case Manager Assessed Client Choice n
37 9 18 53
2.5% < 1.0% 1.2% 3.6%
23 7 7 36
1.6% < 1.0% < 1.0% 2.4%
23 43 31 25
1.6% 2.9% 2.1% 1.7%
15 11 3 9
1.0% < 1.0%