Background
Models | ||||
---|---|---|---|---|
Characteristics | Brokerage and Generalist Case Management | Assertive Community Treatment and Intensive Case Management | Strengths-based Case Management | Clinical Case Management |
Distinctive characteristic | Coordination | Comprehensive approach | Focusing on strengths and empowerment approach | Case worker as role-model and therapist |
Outreaching, service provision at home | Not the priority | Yes | Yes | Yes |
Coordination or service provision | Mainly coordination | Service provision | Coordination and service provision | Coordination and service provision |
Case worker’s or multidisciplinary team’s responsibility | Case worker | Team | Case worker | Case worker |
Growth or stabilization of clients | Mainly stabilization | Stabilization and growth | Stabilization and growth | Mainly stabilization |
Group supervision | No specific information on how it is conducted | No specific information | Following specific steps and focusing on resources development and goals surrounding the client | No specific information |
Average caseload | 35+ | 15+ | 15+ | 10+ |
A review of SMCM studies using the qualitative method
Author(s) (Year) | Country | Sample size | Aims | Findings |
---|---|---|---|---|
Schuetz et al. (2021) [25] | U.S.A. | 34 participants (28 case managers, five supervisors and one children’s service director) | • Understood the process of implementation • Explored how the adapted strengths model for case management impacted the workers and their work with young people | • The model impacted on organizational process and culture, the provision of services and adaptations of the model for young people • Participants expressed that they were satisfied with the model |
Schuetz et al. (2019) [26] | U.S.A. | 34 participants (28 case managers, five supervisors and one children’s service director) | • Explored how SMCM impacted the workers’ work with young people and youth outcomes | • Three themes were: model design and delivery, intermediate impact and long-term outcomes • There was overall satisfaction with the model |
Petrakis et al. (2013) [27]* | Australia | • The number of participants was not mentioned • Three sites (the intensive residential CCU and the two community CCT sites) joined | • Evaluated the implementation fidelity of group supervision in the SMCM | • There was a high fidelity for group supervision for group interaction, client work and by case managers • A standardized approach to group supervision process and documentation facilitated fidelity in implementation |
Tse et al. (2010) [5] | New Zealand | 35 participants | • Examined how SMCM was perceived from the Chinese cultural perspective • Identified the barriers reported by practitioners when they applied the SMCM | • The focus on personal and collective strengths and pragmatic approach were regarded by participants as distinctive features of the model • The service user participants regarded the strengths model as helpful in assisting their settlement and integration into society • Practitioners faced with three challenges: passive role played by service users, difficulties in understanding the concept of strengths and service users with complex needs |
Redko et al. (2007) [28] | U.S.A. | 26 substance abusers | • Explored how people with substance abuse perceived the working alliance with case managers | • A positive working alliance was important to build trust, self-worth and self-esteem • The personal qualities of the case manager and the nature of the client-case manager relationship were crucial • Two principles of SMCM: personal control over goal setting and an emphasis on strengths |
Brun & Rapp (2001) [19] | U.S.A. | • Two project case managers • 10 individuals were experts who joined the Case Management Enhancements Project (CME) | • Explored the participants’ perceptions of SMCM • Compared the participants’ perceptions with the key principles of SMCM | • Individuals’ responses to the SMCM (acceptance of strengths, initial mistrust of the strengths-based approach and hold on to strengths and deficits at the same time) • Individuals’ responses to the professional relationship (acceptance of the relationship, do not need the relationship and felt guilty when failed) |
Method
Study design and setting
SMCM group
Control group
SMCM group | Control group | ||
---|---|---|---|
ICCMW-centre A | Case workers | 3 | 2 |
Service users | 6 | 6 | |
ICCMW-centre B | Case workers | 2 | 2 |
Service users | 3 | 3 | |
ICCMW-centre C | Case workers | 3 | 2 |
Service users | 3 | 3 | |
Total | 20 | 18 | |
Total no. of case workers | 14 | ||
Total no. of service users | 24 |
Dimensions | SMCM Group | Control Group |
---|---|---|
Participants in both groups will attend psychiatric outpatient appointment (if any) and regular programs in the Community Mental Health Centre e.g., community meeting, exercise class | ||
Intervention Integrity & Infrastructure | Ensures a supportive strengths model context through the Fidelity Scale, which was designed to assess the adequacy of SMCM implementation in three core areas: structure, supervision/supervisor, and clinical/service. | No routine fidelity assessment for the implementation of recovery-oriented services. |
1. Structure | Has specifications about caseload ratios and percentage of community contacts. | No specific requirement. |
2. Strengths-based Supervision | Field mentoring and group supervision: provide support and affirmation, ideas and learning. Group supervision following specific steps: ✓ The presenting staff hand out service users’ strengths assessments and specify the help needed from the group. ✓ The team are to clarify the assessment and brainstorm ideas. ✓ The presenting staff review the ideas and state the next steps. | Adopt the existing supervision arrangements. |
3. Clinical/ Service a. Strengths Assessments | Collects information on personal and environmental strengths using the Strength Assessment tool as the basis of work. Assessment is an ongoing process. Domains in daily living, assets, employment/education, supportive relations, wellness/health, leisure, spirituality/ culture. | No specific tool for conducting initial assessments. Unclear how it will focus on assessing people’s strengths. |
b. Personal Recovery Plans | Creates a mutual agenda for work, focusing on achieving the goals that the person has set. Writes down the person’s goals (passion statement) and plan specific steps (short-term goals) to achieve the goals in the Personal Recovery Plan. | Work on specific goals. No specific tool. |
Participants
Data collection and management
Data analysis and research rigor
Results
1. Impacts of interventions | ||
Common impacts: Improved motivation level, better management of one’s emotion, mental symptoms and negative thoughts | ||
Different impacts: | SMCM group | Control group |
Domain of improvement- | Improvements in functional recovery e.g., finding paid employment, widening social circle, more contact with family members, and adopting a more planful approach to achieve one’s goals | General improvement |
Account of the impacts- | Vivid, detailed, rich accounts of how recovery goals were set and eventually achieved | Tended to be straightforward |
One’s own strengths- | Better adjusted to understand and accept one’s strengths, weaknesses and shortcomings | No similar comments were found |
2. Experience of the intervention | ||
2.1 Relationship between service user and case worker: Both SMCM and control group service users appraised the case workers as very helpful and approachable, having regular contact, caring like a family members. | ||
SMCM group | Control group | |
Context- | • Helping service users gain hope and a sense of satisfaction by supporting them to achieve their identified goals, showing a genuine appreciation of users’ strengths and a curiosity to explore their talents and skills | • Being person-centered in therapeutic relationship with service users, showing empathy and trust towards them |
Concerns- | • Once-a-fortnight contact between case worker and service user was too much for user and the potential to build dependence on case worker | • Did not mention any particular concerns |
2.2 Who would benefit from the interventions? Service users’ characteristics were important in determining whether they would benefit from the respective interventions. Both SMCM and control group service users needed to have some insight, willingness to engage in conversations about one’s own recovery process and have some social support. | ||
SMCM group | Control group | |
Service users need to have- | • Stable mental state (e.g., no severe depressive or hypomanic symptoms) • Adequate communication skills | • Good adherence to medications regime • A “normal life”, meaningful daytime engagement • Life skills • Trust in the case worker • Opportunity to make own decisions |
2.3 Specific tools used in the interventions: Control group participants did not mention any particular features of the interventions. SMCM workers commented about- • Found the personal recovery plan very helpful for both case workers and service users • The service users had mixed feelings about how the workers used the strengths assessment and personal recovery plan • The importance of taking part in group supervision where workers could learn from each other and find optimal solutions to the problems they face. Meanwhile, the group discussion was influenced by the worker’s understanding and perception of the user |
Impacts of interventions
There were three distinctive differences between the SMCM group and the control group in terms of the impacts of the interventions. First, compared with the control group, service user participants in the SMCM group tended to mention improvements in their functional recovery more, such as finding paid employment, widening their social circle, making more contact with family members or adopting a more planful approach to achieve one’s goals.“One of the problems that I cannot solve is work. I do not know why I give up so easily. I do not know whether this is a personality problem. In some jobs, I am eager to go back to work at first, but after a few days, I wouldn’t want to work because my mood would have changed. I don’t know why it changes so quickly, and I haven’t been able to solve this problem.” (Service User: 190723_T027_KKF_Control_19)
Second, service user participants in the SMCM group offered vivid, detailed, rich accounts of how their recovery goals were set and eventually achieved.“ … all along I did not like to plan, just do it when I want. I do not like planning. Why bother planning if I would fail anyway–that is too hard for me … but now I am more active in facing the problems … (on the topic of goals) yeah in the (non-SMCM-based) community centre I attended in the past, I was not asked about my ideas, what I wanted to achieve or learn, no one knew really, not even my wife.” (Service User: 181024_T047_WYK_SMCM_59–60 & 66–67)
Participants in the SMCM group expressed that even though not all goals had been achieved, it was important to feel hopeful.“Specifically, when we were talking about certain thoughts – I have my own way of thinking – my case worker would help me to try another way of thinking. … Overall, my case worker provided me with some other options without setting limits for me. She taught me not to care too much whether any business transactions could be done, not to compare the number of people at other stalls. Instead, I should experience the process. She provided me with feedback. Finally, my case worker asked me how the activity was. I felt my experience had been broadened, and I felt like I had cleared a hurdle.” (Service User: 190816_B050_WWH_SMCM_17–21)
Third, the participants in the SMCM group not only referred to learning more about their strengths and talents, growing in confidence, and having a positive outlook about life in general but also elaborated on how they had become better adjusted to understand and accept their strengths, weaknesses and shortcomings. No similar comments were found in the control group.“It (SMCM) is helpful. That is, although it (achievement of goal) sometimes did not work, there is hope … although I can’t achieve the goal, I learn how to think differently, to no longer dwell on the failures, skewing to one side (the unpleasant experience)” (Service User: 181024_T084_LHT_SMCM_78 & 83–84)
“Experience … My experience of this year was that I have accepted my own weaknesses and discovered my strengths. The biggest change is that when a mistake is made, it is no longer that I am right and others are wrong. I make mistakes; I accept myself as I am. Even though people made mistakes, I accepted them. This is the change.” (Service User: 190813_C070_LYW_SMCM _88)
Experience of the intervention
Relationship between service user and case worker
The findings that emerged from the SMCM group were different from those that emerged from the control group in terms of how the therapeutic relationship was related to the goal-setting and goal-achieving processes.“For example, job hunting … She was successful in getting the job. The manager was very nice and asked her to work the next day … She worked for less than five hours … If there is an opportunity, I will still let her try. If it does not work, we can use other means. (Case Worker: 190725_TS05_Control_132)
One distinctive comment was found only in the SMCM group, where two workers felt that the once-a-fortnight contact, which is one of the fidelity review criteria, was rather demanding on service users because some of them already had busy schedules. Furthermore, such regular meetings may lead to service users developing a dependence on the SMCM workers.“The service users also talked more about what they wanted. In addition, their decisions should be respected. For example, Mr. ABC (service user’s name) was not sure whether to look for a job or retire. He also asked whether retirement was a good decision. I did not answer whether it was a good decision or not; instead, I asked what he wanted. He said that he wanted to have good quality of life. Then, I respected his decision. It is not a must to work. So, we discussed life and having some kind of goal after retirement. In my opinion, these are the most important points.” (Case Worker: 190809_CS03_SMCM_28)
“I think the biggest obstacle is time. For some clients who are working, meeting once every two weeks is difficult. When I call them, it sounds like they are very tired. I feel something is not quite right … once every two weeks is difficult. For those clients who work, I will do it once a month.” (Case Worker: 190712_CS21_SMCM_96)
The service user participants from both the SMCM group and the control group readily shared their opinions about many qualities associated with workers in the therapeutic relationship, such as caring like a family member, having regular contact, and being very helpful and approachable. The only apparent difference between the two groups was that the service user participants in the SMCM group elaborated much more when describing the worker–service user relationship, which resulted in very rich and thick narratives. The following account about how a worker helped a user find different ways to cope with work-related stress shows that a very deep relationship existed between the worker and the service user (T047/WYK_A73-80p14–16).“However, sometimes I am not sure whether it (referring to the client’s apparent dependence on the worker) is because we have meetings too often. I feel that the clients may be dependent on us … ” (Case Worker: 190809_CS03_SMCM_3)
“She mentioned that I had to adjust my rest time and showed me how to improve my confidence, how to use methods to sleep better. It was because I suffered from insomnia at that time. My case worker did not want me to rely on sleeping pills, so she taught me to drink a glass of hot milk or something similar to make me sleep better and how to better communicate with others. Ms ABC (worker’s name) helped me a lot. Previously, it was easy for me to lose my temper. When someone said something that was not nice, I would take exception immediately. Now I think about what I want to say, whether it will hurt others.” (Service User: 181024_T047_WYK_SMCM_50)
Who would benefit from the interventions?
Specific tools used in the interventions
The case workers found the PRP very helpful for both staff members and service users.“But there is a difficulty in SMCM group supervision because when we do group supervision, most of us would never have seen the client before. The case worker will present how he/she sees the client. This is an indirect way for others to familiarize themselves with the client. Everyone can interpret the client in different ways. That’s why when I need to introduce a client I am responsible for, I may have my own perception of the client, so my presentation of the client may not totally represent who the client really is. Actually, sometimes it’s a bit difficult.” (Case Worker: 190809_CS03_SMCM_20)
The service users had mixed feelings about how the SMCM case workers used the strengths assessment and PRP. One group of users felt that using the forms was helpful in structuring the case management process and increasing service users’ level of engagement in the recovery process.“I think that the PRP helps us to reach a consensus … it is a basis for us to discuss together and decide on a plan of action. Whether we show the PRP form to a client largely depends on the client. We write down the PRP and show it to the client so they clearly know what they need to do to achieve improved quality of life. We gradually help them take up some interests, hobbies. The PRP obviously helps clients. It is just like students who submit their assignments to teachers. The PRP lists several steps that a client needs to take … I show them the PRP form every time when we meet. I then listen to clients who share their progress. It’s interesting. The clients follow the PRP and continue to work on it.” (Case Worker: 190813_CS02_SMCM_108–109)
However, case workers recalled that some service users found the use of the forms (e.g., the two-page, seven-domain strengths assessment) very stressful.“Interviewer (I): Were the goals which were listed in the PRP form set by you and the worker together in the past year?Service user (SU): Yes.I: Do you remember what goals you set?SU: The first goal is for me to pay attention to my diet and intake of calories. Second, I should take care of myself and my family. I should do some physical exercise, that is, the case worker suggested that I reserve some gym facilities to do some exercise at ABC (Centre’s name) Centre. I made an effort and did some exercise.I: How did you feel when you saw the PRP form that the case worker photocopied for you?SU: I felt good and I made changes. For example, I started doing physical exercise, something I hadn’t done for a long time. I went with my family to ABC (restaurant’s name) restaurant to have a meal together. I seldom talked to my family before, but now I talk to them more.” (Service User: 190813_C070_LYW_SMCM_24–25)“I remembered the form which asked me about what I wanted in the future; that is, I should try to do something that I could do in the future. If I cannot do it, just leave it … it (the PRP form) is helpful. I think it helps me plan for the future … Yes, it encouraged me not to think of my past and not to lose hope for the future. It is helpful.” (Service User: 190821_B012_LYK_SMCM_user_3.33)
“The effectiveness of the model relies on whether the client takes the initiative or whether they accept it. For example, I have 13 cases. Among them, some feel this model stresses them out. In some cases, when I took out the form, they said they felt pressurized and asked whether it was possible not to show it to them. You set the goals for them and they wonder why there are goals and whether they are being required to do something. It’s stressful.” (Case Worker: 190721_CS21_SMCM_26)