Halting the "Revolving Door" of serious mental illness: evaluating an assertive case management program

Abstract

The Canadian mental health service delivery system has been in a state of flux for several decades. By 1955 (Talbott, 1988b), following an example set by the United States, Canadian psychiatric hospitals began the process of "de-institutionalisation". However, there were few programs or facilities in place to support the influx of seriously and persistently mentally ill (SPMI) clients into the community (Higenbottam, 1994). Accordingly, many SPMI clients were unable to live successfully in the community and were frequently rehospitalised. A solution to this problem was the development and implementation of the Assertive Case Management (ACM) intervention model. Research findings in the U.S. have demonstrated that ACM is an effective vehicle for mental health service provision to SPMI clients in the community (Bond, Witheridge, Dincin, Wasmer, Webb, DeGraaf-Kaser, 1990).

My research is based upon a subset of a large database that evolved from the Riverview/Fraser Valley assertive Outreach Program's (AOP) evaluation research component. The AOP research component was designed in 1989 as a two-year demonstration project for the study of two forms of community mental health service delivery systems in a Canadian setting: the community Mental Health Centre (MHC) and the Assertive Case Management (ACM) models of intervention.

The MHC approach is a traditional, clinic-based model of treatment and care. Due to its constraints, this approach is least appropriate for SPMI persons (Witheridge & Dincin, 1985).

The main rationale of the ACM approach is that by employing an "in vivo" approach to the treatment, care, and rehabilitation of clients and by maintaining a relatively high level of client contact (providing life-skills training, helping with basic needs), the program would reduce the recidivism rate of its clients. The AOP evaluation research component spanned two years. The specific focus of my research was delimited to (1) hospitalisation (recidivism), (2) client quality of life, and (3) community living.

The AOP study was an experiment. It took the form of a randomised clinical trial in which 123 clients were randomly assigned to the treatment (T) condition (n = 63) and the control (C) condition (n = 60) in two sites. Both groups received existing community mental health services; the T group received ACM services. Participants all suffered from serious and persistent mental illness and were deemed to be at high risk for re-hospitalisation.

Significant reductions in the hospitalisation variables were reported in all study groups, reflecting significant enhancements to the mental health system during the study period. Additionally, significant site differences were observed indicating differences in the fidelity of the ACM model implementation at the two study sites. The discussion focuses on the public policy, program planning, and evaluation issues associated with community mental health research.