Rosen A, Teesson M. Does case management work? The evidence and the abuse of evidence-based medicine. ANZJ Psych 2001 35;6:731-746
Dear Colleagues,
This paper is long and complex, but its essence seems to be that to in order to be effective, 'case management' needs to be used for high risk subjects and only when implemented by professionals in the field. As a working definition, case management might be termed: "active and assertive community treatment" or better still: "patient care co-ordinated by a single professional using a multi-disciplinary approach". With minor changes, this is believed to apply to dependency matters just as it does to community psychiatry where most of the current evaluative research has been done. More than twelve randomised controlled studies comparing case management with 'standard therapy', from a variety of countries - including Australia - contributed to a Cochrane database on the subject.
Some have considered case management (CM) as a 'motherhood' subject, ineligible of criticism or modification. So much so that I once considered it an imaginary concept, like Falstaff's "honour" monologue. But as long as it is seen in concert with good quality medical care it is a useful way of examining and implementing psychosocial supports.
If not by name, case management comes naturally to GPs since this is just what they do as a matter of course. Hospital specialists and clinic based health workers may have more clearly demarcated duties and thus be less likely to address a patient 'holistically'. It is still possible, however, for any health professional to take the time to examine various aspects of the patient's life and coordinate an approach to address those areas needing attention. It is sometimes straightforward but at other times the high risk areas need to be teased out of a difficult presentation by subjects who may be 'in denial' or unable to recognise the issues themselves due to the circumstances.
Of fundamental importance is the aspect of medical treatment and its quality in relation to the current evidence base. Addiction treatment is in these respects possibly even clearer than in community mental health. There is some debate as to who is responsible for appropriate medical care. Courts generally find that it is the doctor who is responsible for inadequate medical care. It might be argued, however, that other health care workers are almost equally responsible in matters of diagnosis and treatment, despite sometimes their having no training in therapeutics. The doctor may not always be involved in the first instance. Thus to this point others must take the responsibility for assessments and treatment given (or not given). In the community it is normally the patient who decides when to go to the doctor (or the dentist, or the hairdresser for that matter). But in the health care system, there often needs to be a key worker who does significantly more than a travel clerk booking a ticket on request.
comments by Andrew Byrne ..
References:
Pringle JL, Edmondston LA et al. The Role of Wrap Around Services in Retention and Outcome in Substance Abuse Treatment: Finding From the Wrap Around Service Impact Study. Addictive Disorders Their Treat (2002) 1;4:109-118
