CLINICAL HANDBOOK OF SCHIZOPHRENIA

31. Clinical Case Management 315with individuals and families; skills training in the community via modeling and in vivopractice; substance abuse counseling; and so forth. Less is known about the level oftraining in clinical case management skills or the level of expertise with which theseskills are applied.Nevertheless, when case management models that include some clinical skills arecompared with service brokering models, evidence suggests that they do result in modestlysuperior outcomes that include reduced hospitalizations and improved psychosocialfunctioning. To illustrate, one experimental comparison by Morse and colleagues (1997)demonstrated differential outcomes between an ACT program and broker-style case management.In the ACT program, practitioners cultivated a positive working relationshipwith clients, emphasized practical problem solving, enhanced community living skills,provided supportive services, assisted with money management, and facilitated transportation.By contrast, in brokering, case managers purchased services from various agenciesand helped clients to develop treatment plans. ACT provided considerably more servicesoverall (including housing, finances, health and support) and resulted in greater client satisfactionand better psychiatric ratings. However, no differences emerged with regard tosubstance abuse outcomes. As is typically the case in ACT programs, staff-to-client ratioswere much smaller (about one-eighth) than that in the brokering case management condition.Thus, it is hard to determine in this exemplar and in similar studies whether thebetter outcomes for ACT were the result of more services, different services, or qualitativelybetter service delivery.Considerable limitations in most of the research on case management interventionsin general include the aforementioned lack of clarity in model conceptualization, alongwith inadequate sample size, lack of pretreatment data on clients, problems with randomassignment of cases, high rates of attrition, limited use of standardized measures, violationsof statistical assumptions, lack of multivariate analysis, poor distinctions amongtreatment conditions, and lack of attention to intervention fidelity (i.e., faithfulness to thepractice model).Notwithstanding these limitations, tentative conclusions about the effectiveness ofclinical case management can be drawn. Case management shows positive outcomes inclients’ lower hospital stays overall, increased social contact and social functioning, increasedsatisfaction with life, some reduction in symptoms (perhaps through medicationcompliance), increased family and patient satisfaction, improved social functioning, andbetter adjustment to employment and independent living. Although tying specific dimensionsof clinical case management to specific outcomes is difficult, a few reports offer evidencethat the therapeutic relationship between the case manager and the client may be akey factor that accounts for the modest superiority of clinical case management over broker-styleapproaches.TREATMENT GUIDELINES FOR CLINICAL CASE MANAGEMENTIf one extrapolates from controlled outcome research on clinical practices with the seriouslymentally ill, it is reasonable to hypothesize that much can be done to improve theeffectiveness of clinical case management through the incorporation of some of the followingtreatment strategies:1. Engagement and motivational enhancement skills.2. Nurturing a sound therapeutic relationship.3. Crisis intervention.