Background
The concept that people should have a stronger voice in decisions about their health and care has been a policy goal in health for at least 20 years [
1] with increased consumer involvement linked to improved care experiences and better clinical and economic outcomes [
2]. In mental health care, case management is the established model for care provision and aims to integrate care and support across a broad range of services for individuals presenting with complex needs [
3]. As there is no single definition of case management, for the purposes of this review, case management and care planning are explored utilising Ross et al.’s [
4] framework of case-management with core components including: case-finding; assessment; care planning; care co-ordination and case closure.
Case finding in this review refers to consumers on a CTO. The care planning process, informed by ongoing assessment, should be personalised to the individual, address the range of issues that may impact upon their health and wellbeing and be co-produced with the person and relevant others involved in their care [
4]. Care-coordination, ‘the essence of case management’ , requires case managers to collaboratively facilitate the above processes with the care plan the ‘live’ document recording this process [
4]. Case managers working with consumers on CTOs have the additional role of managing the CTO requirements, which may include informing the consumer and family about CTO processes, participating in tribunal hearings, initiating recall to hospital and managing discharge from the CTO [
5‐
7].
Central to case management in mental health is the therapeutic relationship, with positive associations found between ‘perceived patient involvement, satisfaction and empowerment’ [
8,
9]. A recent systematic review examining barriers and facilitators to consumer involvement in care planning in mental health found consumer involvement was dependant on consumer capacity, the relational quality between consumers and health professionals and the organisational context, with the relational aspects of care planning most valued by consumers and their carers [
8]. However despite benefits and policy support of increased consumer involvement, there has been limited progress towards fully involving people in their own health and care [
1].
In mental health care a further challenge for clinicians is that forced care sits within service frameworks promoting recovery-oriented and person-centred care. The World Health Organisation state that ‘[p]ersons with mental health disorders should be provided with health care which is the least restrictive’ and that ‘maintaining legal instruments and infrastructures…to support community based mental health care’ is central to the implementation of this principle (p.8) [
10]. Thus legal frameworks have been created to ensure individuals with a mental illness, whom are considered to pose a risk to themselves or others receive care and treatment through the use of CTOs [
11]. Though CTOs typically last between 6 and 12 months, in reality many consumers will be on orders for extended periods [
12] with rates of usage increasing in Australia [
13].
Clearly challenges exist for mental health clinicians engaging consumers on such orders in ways that promote self-determination and empowerment. The issue of care planning with consumers on CTOs is complex, with CTO legislation, service delivery models and resource availability all impacting upon implementation [
14]. Significant concerns regarding the effectiveness and ethics of CTOs also exist with a recent review examining CTO effectiveness finding no differences in social functioning, quality of life or service use for individuals on CTOs compared to those receiving standard voluntary care [
15]. Advocates for CTOs cite clinical improvement and being the ‘least restrictive’ treatment option as benefits [
16,
17], whilst advocates against CTOs, often ex- service users, consider forced treatment a major barrier to collaborative, person-centred care [
18]. Further ethical concerns have been raised about current legislation for compulsory treatment in Australia where there is a lack of consideration of the individuals’ decision-making capacity [
11].
In summary, though case management has been used in practice for several decades, there remains a lack of conceptual clarity of what personalised care planning is [
19] and lack of evidence regarding its effectiveness [
4,
20]. In mental health care, compulsory care further challenges concepts of personalised care planning. Over the past 20 years there has been significant debate in the literature about the purpose, value and stakeholder experience of CTOs. This review explores the impact of CTOs on case management. The intention is to add to the current evidence base with the aim of improving the process and experience of case management for all stakeholders, and specifically the experiences and outcomes for those consumers who find themselves on such orders. The integrative review method was the chosen methodology as it allowed for the inclusion of a broad range of studies from diverse empirical sources which was considered important in addressing this complex issue [
21].
Objectives
To gain an in-depth understanding of consumers’ , carers’ and mental health workers’ perspectives and experiences of care coordination and care planning for consumers on CTOs in community mental health settings.
Broader issues that support effective case management
Various broader issues impact upon the effectiveness of case management and consumer outcomes. These include resources, manageable caseloads, effective linking with stakeholders from different service sectors and continuity of care [
4]. These broader service issues were referred to in several of the included papers. Limited resources and service availability were reported to impact on decisions around CTO use as well as result in increased use of CTOs to facilitate early discharge from inpatient services [
31,
37,
48] and access to limited inpatient beds [
29,
31]. Psychiatrists reported high caseloads, insufficient time available to spend with consumers and reduced service options in rural areas [
7].
Few studies reported on links with a broad range of stakeholders. Light et al. [
65], exploring links with primary care, found a lack of integration between primary care and mental health services, though reported some instances where systems were established to enhance shared care between GPs and mental health services. Gibbs et al. [
28] reported a lack of linking of mental health teams with supported accommodation services. Even within mental health services, workers referred to a ‘silo-mentality’ with poor communication and poor linking between inpatient and outpatient services negatively impacting upon consumers [
31,
37,
40]. Lack of continuity of care was also found to lead to increased tensions for workers, for example when workers were required to adhere to CTO conditions put in place by others [
48,
67].
Discussion
The studies included in this review provide rich data that relates to consumers, carers and mental health workers perspectives and experiences of care coordination and care planning for consumers on CTOs in community mental health care settings across a range of countries. Many of the issues also relate more broadly to those individuals whom have a mental illness and may present with complex needs. Models of case management differ in terms of staffing, caseload number, contact frequency, length and availability of service and treatment options and responsibilities [
68]. Understanding the various issues that impact upon the implementation of CTOs, including service delivery models and resources is important in order to inform best practice [
24].
A key finding of this review was the lack of connection between CTO goals (which are service driven) and recovery goals (which are consumer driven), with minimal reference made to care plans documenting the care planning process. Furthermore given the lack of consumer input and knowledge of care plans, it was difficult to substantiate consumer involvement [
40]. Several papers identified the need to link CTO goals to treatment and consumer goals [
5,
24,
30]. Such linking would promote collaborative care planning, facilitate care that is person-centred (and not overly focussed on service goals of medication compliance) and promote service responsibility and support with the consumers’ broader goals, including discharge from orders. Even linking CTO purpose to treatment goals would enhance worker accountability.
Lack of clarity of the purpose of CTOs further complicates linking CTO and consumer goals. Kisely and O’Reilly question if the purpose of the CTO is to ‘reduce revolving-door admissions, provide a less restrictive alternative to involuntary admission, prevent violence by people with severe mental illness, or increase stability and promote recovery’ (p.415) [
69]. The CTO purpose will impact upon both the focus of interventions and expected outcomes including ‘hospital use, perceived coercion, violent acts and quality of life’ (p.415) [
69]. This is important given the lack of clarity regarding discharge from orders. CTO processes of assessment, review and discharge from orders are incorporated into the case management role. In Australia, mental health tribunal reviews are conducted 12 monthly. In addition to these formal reviews, care coordinators are required to regularly review an individual’s care (typically 3 monthly). This multidisciplinary review process provides regular opportunities to review changes against both CTO and individual recovery goals, ensure required supports are in place, prompt consideration of discharge and ensure consumers are not left languishing on CTOs. There was little evidence of regular reviews and early discharge from CTOs in the included studies and only three studies that recruited all key stakeholders involved in the care planning relationship. Further exploration of how case management can better incorporate and manage issues related to CTOs is warranted.
A core component of care planning is identifying and implementing relevant evidence based interventions [
4], yet none of the included studies specifically examined the usefulness of focussed interventions. Studies exploring the use of crisis planning and advanced directives identified in the search specifically excluded individuals on CTOs [
70,
71]. Increased stakeholder participation (of workers, consumers and carers) during mental health tribunals was recommended to enhance decision-making related to CTOs [
24], with a particular focus on promoting consumer participation in early stages of CTO implementation [
48]. Shared decision-making (SDM) is a core concept in care-planning and builds on person centeredness by promoting mutual expertise and determining the individuals ‘preferred role in the decision-making process’ [
19]. In mental health care, SDM is often referred to in the context of supporting consumers’ to make informed decisions related to medication [
72,
73]. A recent randomised trial of a patient decision aid for individuals with PTSD, reported increased consumer knowledge of their condition and reduced conflict regarding treatment choice [
74]. Recent studies aiming to enhance medication compliance of consumers with mental health problems have explored the use of peer workers [
75], motivational interviewing [
76] and treatment adherence therapy [
77] with results indicating some success. Given consumer dissatisfaction with their level of involvement in care planning, decisions related to the CTO process, and over focus on medication, focussed interventions to enhance decision-making and medication compliance for consumers’ on CTOs are important areas to further explore.
Various recommendations for practice were made in the included studies. Mfoafa-M’Carthy and Shera considered ‘CTOs should be a voluntary contractually based community treatment option of last resort’ (p.76) [
68] and suggested providing less coercive support options for people with serious mental illness, including intensive case management and use of advanced directives to increase collaborative care planning. Brophy and McDermott [
24] took a more pragmatic approach, and acknowledging CTOs were part of current mental health care, sought key stakeholders perspectives on how to “do CTOs well”. Identified principles of good practice included: taking a human rights perspective (being aware of peoples’ right to self-determination); being transparent regarding CTO goals and purposes and linking these to treatment goals; providing quality services (including continuity of care and evidence-based interventions); facilitating involvement of consumers and their carers’ in the CTO process and development and use of direct practice skills (including linking with support staff and development of advanced interpersonal skills) [
24]. Similarly, Lehssier et al. [
19] emphasised the need for case managers to have advanced practitioner skills, such as SDM and motivational interviewing.
Stuen et al. [
43] found an assertive engagement approach with psychosocial interventions was as beneficial as the CTO in engaging ‘reluctant consumers’ in treatment. Similarly, Churchill et al. [
78] conducted a comprehensive review of research of experiences of CTO use internationally and recommended exploring the ‘potential therapeutic gains [that] might be better delivered by enhancing the quality and assertiveness of community treatment for high risk patients’ through, for example, ACT’. Core elements of ACT include ‘assertive engagement, small caseloads [and] focus on supporting broad life domains’ (p.11) [
43]. Whilst this approach has clear benefits in engaging consumers around their identified goals, referral to services that are able to provide psychosocial support is more widely available and should be considered more often than was evident in the studies [
24]. In addition to linking with broader services, the recovery literature recommends a focus on linking consumers with their personal and community resources to support everyday connections and reduce dependence on health services [
79]. There was little reference of such linking in the included studies other than with consumers’ families, and a few reports of links with GPs and accommodation services [
39,
65].
Most papers made reference to the coercive nature of CTOs and potential impact on the therapeutic relationship, which is key to effective case management. Some authors whom have published extensively on involuntary psychiatric treatment have backgrounds in socio-legal research and/or social work. Brophy and McDermott for example used critical social work theory to explore best practice with individuals on CTOs, and highlighted the role this theory has in ‘encourag[ing] social workers to be mindful of the imbalance of power that is inherent in all social work practice’ (p.74) [
24]. In clinical practice, case managers have varied professional backgrounds and may be less sensitive to some of the issues of care and control inherent in the care relationship, as these issues may not be addressed in undergraduate training. Lawn et al. highlight the potential for the relationship between mental health workers and consumers to ‘either assist or obstruct recovery’ (p.14) [
45]. Key components of the therapeutic relationship in the context of forced treatment included empathic skills and trusting relationships [
45]. Consumers who trust health services and workers have better clinical outcomes and report increased positive care experiences [
80]. Trusting relationships are considered ‘a prerequisite to the negotiation of reciprocal agreements [which], in turn, lead to patient-centred care’ (p.886) [
81]. ‘[Worker] characteristics that have been shown to encourage patient trust [include] ability (also termed competence), benevolence, integrity, respect, and honesty’ (p.7) [
80]. The role these relational factors have in facilitating therapeutic alliance has a longstanding and robust evidence base, however Davidson and Chan [
82] warn that it should not be assumed that such skills are already being practiced, and that empathy skills should be developed and maintained with targeted training, reflection and supervision [
45,
82].
Limitations
Appraisal and data extraction was conducted by only one author, though opinion was sought from a 2nd reviewer to clarify studies for inclusion. A limitation of qualitative studies is a lack of generalisability to broader contexts, though the integrative review method of synthesising data from different studies conducted in different locations helps address this. Quantitative studies were not reported in detail, with the decision made to utilise these data to augment the more in-depth qualitative findings in order to best answer the research question.
Conclusion
The effectiveness of case management will be influenced by various factors, including the quality of relationship established between consumers and workers and the type of support offered to consumers. These factors are interrelated and dependent on good assessment of needs, as well as resources available in the community (inclusive of housing, financial security, substance abuse programs and supports to facilitate social connections) [
38,
68]. As Davidson [
83] points out, ‘personal choice plays a very limited role, … when the person has very limited, if any, choices to begin with’ (p.366) [
83]. CTO legislation, service delivery models and resource availability all impact upon the implementation of CTOs and need to be considered when exploring best practices [
24] {Brophy, 2013 #807; }. Changes at the level of clinical practice however can still positively impact on consumers’ experiences of CTOs. The conflicting processes of reciprocity, which involves mutual trust, and authority in current mental health practice needs to be recognised [
81] with person-centred approaches requiring core practitioner and communication skills including empathy, trust and hope [
19]. Workers should aim to engage in the care planning process in ways that enhance consumer experience (increased consumer involvement and addressing identified consumer needs) whilst being sensitive to the ‘control and care’ dynamic of the relationship.
Acknowledgements
The authors would like to express appreciation and thanks to Raechel Damarell, Senior Librarian for Medicine, Nursing and Health Sciences, for her invaluable help with developing the search strategy and searching and Dr Adam Gerace, Research Fellow, School of Nursing & Midwifery, for advice regarding appraisal of quantitative studies.