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Essay: An Evaluation of Cost Related to Individuals Awaiting Case Management

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Mental health over the past few years has risen to the forefront of issues to pay attention to in Canada, specifically since the major shift from deinstitutionalization in the 60’s (Davis, 2006). The locus of treatment has shifted away from a strict medical model to one that is emphasized in human dignity, recovery, and prevention; beyond the scope of symptom management (Davis, 2006). Mental health is complex and pertains to more than just the individual and their mental and physical health. It directly and indirectly affects every Canadian (Public Health Agency of Canada [PHAC], 1999). Mental illness affects people of all occupations, educational backgrounds and income levels; distribution of illness is not random or uniform and no one is immune (PHAC, 1999). At some point in a Canadian’s life, they will be affected by mental health or illness in a family member, friend, work colleague, or themselves (PHAC, 1999). It is estimated that nearly one in five Canadian adults will experience a mental health problem or illness during a one year period which accounts to more than 6.7 million people (PHAC, 1999; Mental Health Commission of Canada [MHCC], 2013). That number is equivalent to approximately twice the population of Toronto. When dissecting mental health, personal effects, while important, are sometimes lost in the focus surrounding the cost associated both directly and indirectly to mental health.
Mental health problems and illness can be treated effectively, but for some the duration and intensity of symptoms, feelings and thoughts may seriously interfere with everyday life (PHAC, 1999). For those, mental illness is considered chronic or persistent. Chronic or persistent mental illness is the term mental health professionals use to describe mental illnesses with complex symptoms that require ongoing treatment and management (Davis, 2006). This would include diagnoses of Schizophrenia, Schizoaffective Disorder, Delusional Disorder, Psychosis not-otherwise-specified, and other psychotic disorders, Bipolar Disorder, also known as Manic-Depression, severe depression that resists treatment and impacts ability to function and Personality Disorders that are severe enough to prevent functioning (University of North Carolina School of Medicine, 2014). While smaller in number, it is estimated that roughly 1 in 17 people suffer from chronic or persistent mental illness (University of North Carolina School of Medicine, 2014). While treatable, people with chronic/persistent mental illness may need times of more intensive support, requiring assistance with everyday life activities, housing, work and social support.
It is well known that people with mental illness are more vulnerable than people without. People with chronic/persistent mental illness have higher lifetime disability rates, mortality rates, higher prevalence of substance abuse, poor socioeconomic status, decreased physical health, increased risk to be homeless or are homeless, greater risk for injury, illness and exploitation as well as increased rates of involvement with the criminal justice system (Davis, 2006, p. 9-12). Providing support, care and services to people with chronic/persistent mental illness can decrease some of the negative risks as previously mentioned.
Aside from impacting the quality of life of a person, the economic impact is for some less likely to be ignored. Currently a conservative estimate of the total costs associated to mental health problems and illness in Canada is $50 billion per year (MHCC, 2013). A study completed by the mental health commission of Canada found that approximately $42.3 billion in 2011 was spent on providing care, treatment and support for those individuals with a mental illness (MHCC, 2013). In total the cost of both of these figures is expected to exceed well over $2.3 trillion in the next 30 years (MHCC, 2013). The economic impact surrounding mental illness is important as the Public Health Agency of Canada reported that mental health and mental illness had the highest direct care costs in Canada (MHCC, 2013). People with mental illness utilized more high cost resources, such as longer stays in hospital and increased use of specialist visits (MHCC, 2013). Being able to provide the necessary care and support for individuals with mental illness could lead to decreasing the overall cost of direct care by having supports readily available and accessible outside the realm of hospitals. As well it could indirectly cut down costs associated to loss of job productivity, homelessness, and incarceration.
Over the past several years there has been growing concern surrounding these ‘high cost users of healthcare’. This term refers to the small portion of the population that accounts for the most health care service usage (Bains, 2012). When looking at Ontario specifically, the top 10% of high cost users only account for 3% of the province’s actual population, as seen in appendix A (Bains, 2012). The costs associated to this group roughly accounted for 75% of the costs, around $11 billion, as seen in appendix C (Bains, 2012). Further breaking it down it amounted to be an average cost per patient of $27,200, as seen in appendix A (Bains, 2012). When specifically focusing on mental health ‘high cost users’ or HCU’s, they represent less than 1% of the actual population but account for 25% of hospitalization days in acute care, as seen in appendix B (Johansen & Fines, 2012, p. 3).
Mental health diagnoses, whether the most responsible or co-morbid, are associated with longer hospital stays (Johansen & Fines, 2012, p. 5). On average this amounts to two and a half times longer than those not involving a mental health diagnosis (Johansen & Fines, 2012, p. 5). With having an increased length of stay in hospital, the cost associated with acute care increases and puts stress on an already limited availability of mental health acute care. There also continues to be a percentage of individuals who are hospitalized that remain in hospital after their care has been completed (Johansen & Fines, 2012, p. 5). This is due to a lack of supports in the community or their on-going post acute care needs (Johansen & Fines, 2012, p. 5).
In Ontario, the Local Health Integration Networks (LHIN’s) are responsible for providing the planning, funding and integration of health care services (Local Health Integration Network [LHIN], 2006). They are accountable for public funded hospitals, Community Care Access Centres, Community Support Services, Long-Term Care, Mental Health and Addiction services and Community Health Centres (LHIN, 2006). Currently the LHIN’s are looking at ways to decrease the cost of HCU’s and address the needs of individuals experiencing mental illness by shifting individuals to resources and care in the community. The idea of community care is not a new concept as the push for individuals to reintegrate back into their communities has been the primary focus for mental health since deinstitutionalization.
After discharge from hospital, individuals who suffer from chronic mental illness are linked with community services to receive ongoing care as a way to diminish the likelihood of relapse or number of relapses and increase overall quality of life. The current standard of care is through the provision of case management (Chan, Mackenzie & Jacobs, 2000). Currently there are varying types of case management and this proposed study will look at both standard case management and more intensive case management also known as Assertive Community Treatment (ACT).
Previous studies have looked at the cost and benefits of community mental health primarily evaluating case management as the standard of care outside of the hospital. Studies have shown the cost effectiveness of case management in comparison to hospitalization but have yet to look at the unintended costs associated to individuals on the waitlist for case management. Currently in Lambton-Kent the wait list for case management services is approximately one year which can vary depending on case severity and priority. During this wait period clients do not have access to the cumulative support that is provided through case management. They do have access to crisis services should they need assistance while waiting for services and can have assistance with basic needs.
This research proposal will attempt to address the gap in knowledge by examining service utilization and unintended costs related to individuals who are currently on the waitlist for case management through CMHA Lambton-Kent. The focus will surround publicly funded services and direct costs related to care.
Literature Review
The review of literature consisted of information from several professions including Social Work, Psychology, Nursing and Economics. Databases that were used include OVID, PsycINFO, Medline via OVID and EconLit. No results were found when the topic area cost-effectiveness of waitlists for mental health was searched. The alternative topic area was changed to cost-effectiveness of case management for mental health. Population characteristics included adults with severe/chronic/persistent mental illness. The time frame that is included in this review covers 1997-2001. The studies all included the key words cost effectiveness, severe mental illness and case management. There were no current studies that were available to access or fit the criteria of the topic searched.
All literature reviewed argued that case management provides the basis of service for people with severe/chronic/persistent mental illness (Chan, Mackenzie & Jacobs, 2000; Burns et al, 1999; Hassiotis et al., 2001; Johnston et al., 1998; Ford et al., 1997). Case management is seen as a method of organizing client care that improves outcomes for clients as compared to traditional forms of support (Chan, Mackenzie & Jacobs, 2000). A meta-analysis of 24 studies focused primarily on the effectiveness of case management for the severely mentally ill concluded that 75% of people who participated fared better than clients who did not receive case management (Gorey et al., 1998). Case management is based on the function of reducing inappropriate use of public hospitals and also improving the continuity of care by linking services with the client (Franklin, Solovitz, Mason, Clemons & Miller, 1987). Case management is unanimously favored as a method of treatment due to maximizing the effectiveness of services that currently exist (Franklin et al., 1987). This is crucial as funding has shifted from federal governments to provincial and local governments (Franklin et al., 1987). Early studies debated the effectiveness of case management, arguing that it is not conclusive to say that case management improves the quality of life for individuals with a severe mental illness (Franklin et al., 1987). Despite arguments made by various researchers, case management continues to be the standard of care for individuals with chronic/persistent mental illness. The use of case management is not limited to North America and is frequently used worldwide as a method of care (Chan, Mackenzie & Jacobs, 2000).
Moving away from the fundamentals of case management as a method of treatment, several research studies compared the cost effectiveness of case management for severe mental illness with methods of either standard case management or traditional methods of treatment. The results from 4 major studies found differing results in regards to costs. One study focused on Dual Diagnosis and concluded that case management resulted in savings of cost for that population (Hassiotis et al., 2001). Two studies compared cost effectiveness of standard case management with intensive case management and found that standard and intensive case management showed no difference (Burns et al, 1999). Another study agreed with a previous study that case management was not cost effective; however would need to be further explored to determine if the benefit provided justified cost (Johnston et al., 1998; Ford et al., 1997). Overall the literature surrounding the cost effectiveness of case management was inconclusive and does not correspond to the focus of this papers proposed research. This area needs to be further explored; however inconsistencies with how case management is carried out through different agencies increases the difficulty of assessment.
The information reviewed only pertained to individuals who were receiving case management services and not those who were on wait lists. While understanding methods of treatment is important, under explored are the costs associated with those who are waiting for long periods of time to access case management services. No single study has been completed to determine if long wait times for individuals contributes to increased cost of health care. Specifically high cost health care services as mentioned earlier.
The available research has various limitations that could contribute to misrepresenting the true findings of each study. All studies reviewed focused primarily on individuals diagnosed with Schizophrenia or Psychotic Disorder and disregarded a multitude of other diagnosis that fall in the category of chronic/persistent mental health. As well, none of the studies evaluated incarceration data or information surrounding the possible reduction of involvement with the criminal justice system. All studies did not include individuals in psychiatric hospitals, and service delivery varied among profession; social workers, nurses and other trained mental health professionals. The studies completed were not conducted in Canada which presents an issue as it provides no information in regards to individuals who identify as aboriginal, which Lambton-Kent has a large aboriginal population. The studies again only focused on those receiving case management and not those awaiting service. The results of improvement were dependent upon the delivery and quality of care which can vary between agency and worker. Therefore the reviewed literature does not provide information surrounding the topic of the proposed research which needs to be further explored.
Despite inconsistencies across all reviewed literature, a common factor is the theoretical framework that guided each study. Due to the focus on cost-effectiveness and the emphasis placed on ensuring the maximization of public dollars, neoliberal theory is evident. Policy regarding social spending is dependent upon the government in power and currently in Canada a neo-liberal government has been in charge for a fairly long period of time. The major components of neo-liberalism are evident throughout these studies, as well as frame the proposed study. The main focus being a reduction of the welfare state and social spending; opening the opportunity for increased privatization in health care (McKenize & Warf, 2010, p. 42). The push from policy makers is not to expand on the current funding but to maximize the amount of money already allocated and reduce costs as much as possible. This proposed study will look to answer what are the unintended costs of people seeking and receiving services when placed on a wait list for case management services? As well as what are the factors that contribute to the unintended costs associated with using alternative services while on the wait list? The proposed study believes that individuals on the wait list will continue to access high cost services and remain high cost users of healthcare without case management service; the opposite of what LHIN’s are hoping is occurring with the shift to increased community involvement.
The proposed study will be a cross-sectional cost benefit analysis that will take a look at the case management waitlist at CMHA Lambton-Kent for a period of one year. It will compare the costs of case management with the unintended costs associated with waiting for services. This study will help inform further decisions on possible resource allocation for increased funding for case management. A cross-sectional cost benefit analysis was chosen due to consistent and continuous monitoring of clients over the time frame of a year. This research design will compare the cost of inputs for case management with the outputs and outcomes of being on the waitlist for services.
The characteristics of the sample involve a wide array of individuals who have specific mental health needs. Individuals can vary in age from 16 years of age to 65 plus years and vary in demographics including, age, race, gender, and cultural background. All individuals must live within the catchment area of Lambton-Kent. Specifically each individual will have a chronic or persistent mental illness as previously mentioned or are in query of a diagnosis. Each individual as well must have completed the intake process and have been assessed for eligibility for case management services. This can and includes eligibility for Early Intervention/ First Episode case management, General case management, ACT, Dual diagnosis case management and Concurrent Disorders case management.
The sampling method is non-random purposive convenience sampling as the study is relying on specific individuals who are available to the researcher. The sample is not representative of the general population; however the study is focusing on specific information that only pertains to a smaller group which are represented in this study. The study looks to gain information from the individuals who have already been assessed as eligible for case management and are awaiting services.
The sampling frame used for this proposed study is specific as it includes individuals in the Lambton-Kent area who have completed an intake appointment with CMHA and are eligible for case management services.
Individuals will be invited to participate during their intake appointment and will be offered an incentive upon completion of the study. Individuals have the right to refuse participation and it will in no way affect their service wait time or ability to participate in services should they be eligible. Ideally all individuals eligible for case management would participate as it is a requirement to participate in wait list monitoring (WLM) every three weeks while awaiting service, regardless of study participation.
Currently individuals who are eligible for services are contacted every three weeks to assess need, risk and provide necessary supports while waiting for service. Data would be collected during this process as it would create no additional burden for a few more minutes of an individual’s time. During WLM participants will be asked additional questions to identify the services they have accessed as well as the number of times. The WLM process consists of a set of structured questions, and answers are recorded through notes taken by the crisis staff, as seen in appendix D. When possible, client information is taken verbatim or as close to verbatim as possible.
The data collection is completed by trained mental health professionals, primarily crisis staff, ensuring that should an individual require support, adequate measures could be provided. This as well ensures that despite wait times, individuals can access some form of support while waiting for services. Participants are primarily contacted over the phone or can attend the agency to meet in person with staff. This is based on the individual’s availability to access a telephone. As well, for some cases crisis staff can meet with the individual in the community dependent on the need and safety risks of the individual.
Information is entered into the pre-existing agency database under the forms currently used for WLM. Forms that are completed by hand or out in the community are placed into the database before the closure of each business day.
The measurement tool used for this study will be the pre-existing Needs Assessment for Intake and Social Work Waitlist which can again be found in appendix D. This form was developed by CMHA Lambton-Kent to assist in the WLM process to track information about individuals who are awaiting service. This form is accessible through the current agency data base and information can be inputted directly into the clients file after information is collected. Basic demographic information is collected during the initial intake process and is coded by the client’s unique number and kept in the client file. The WLM form is not a standardized measurement tool but is consistently used by CMHA for the purpose of gathering information from the clients own report of symptoms and experiences during each three week time frame.
Self report is valid for some application of the questions as it is dependent on what the individual feels their symptoms are and the severity of those symptoms. Due to the spectrum and uniqueness of each individual’s illness no standardized test could be utilized to capture a valid picture of all of the client’s needs. Self report of times in hospital and length of stay could be crossed referenced with hospital records as CMHA has access to Blue Water Health’s hospital data base; however its shortfall is that it only pertains to when clients are admitted to the Mental Health Inpatient Unit (MHIP). Client’s number of times accessing the crisis nurse or emergency room are based on client report. This also pertains to client involvement with the criminal justice system and times arrested or time incarcerated. Information regarding involvement with corrections could be cross referenced with information gathered by the Release from Custody worker and program at CMHA but would only pertain to clients who were incarcerated.
Information surrounding other services used could potentially be crossed referenced by obtaining consent from each client however is unrealistic to this study as it could possible deter clients from participating as well would create further issues in regards to other agencies not wishing to participate. For the purpose of this study this measurement will be seen as a reliable and valid measure as it is a starting point for information gathering regarding this specific issue.
Analysis of collected information will be completed by an outside researcher to ensure the integrity of the information collected stays intact. Answers on the WLM form will be coded using assigned values for specific categories such as age, sex, number of times admitted etc. For participant information that is more than just a nominal answer, simplified answer categories will be created to assign codes to those answers that seem most alike. Univariate analysis will be used to examine the frequency distributions between demographic data. Central tendencies will be completed on demographic data and also the amount of times participants report being hospitalized, visiting the ER or crisis nurse, time in jail, run ins with law enforcement and other publically funded agencies accessed. Standard deviation will be calculated to determine the distance away from the mean in relation to the category of data. Multivariate analysis will be completed to address relationships between age, diagnosis, and hospital service utilization, as well as other relationships comparing categorical data with demographics. Measures of association will also be calculated to evaluate the strength of relationship between variables using Pearson’s correlation. Multiple regression will be used to reduce the variable set to those that are directly associated with cost (Byford, Barber, Fiander, Marshall & Green, 2001).
For analysis of cost in this study, cost will be calculated by multiplying the number of units of each client by the unit cost. Unit cost will be derived from provincial expenditure data on publically funded services as LHIN’s contribute money to publically funded services and not privately operated facilities (Ford et al., 1997). Cost of case management will be derived from the salary costs of case managers at CMHA Lambton-Kent. Mann-Whitney U tests will be completed to compare the cost of case management with cost of services utilized while on the wait list for service (Ford et al., 1997).
Potential Funding Sources
When discussing potential funding sources for this proposed research, the initial thought pertains to entertaining the idea with CMHA Lambton-Kent as the data directly reflects their agency. As well the findings of the study could lead to pursuing additional resources in increasing the case management services for that specific agency. CMHA Lambton-Kent does have funding available to support research and could carry this proposal into action. A second viable option could be the LHIN as they are the funders for public mental health services in Ontario. This study could be beneficial as it could potentially cut down on costs in regards to high-cost health care services related to mental health. This fits well with the LHIN’s mandate to ensure health care dollars are spent efficiently and effective (LHIN, 2006). A third and final potential funder could be the Ontario Mental Health Foundation (OMHF) as their aim is to promote the mental health of people living in Ontario to improve treatment and rehabilitation (Ontario Mental Health Foundation, 2013). The OMHF is also known to be a large supporter of mental health research and could support this research proposal (OMHF, 2013). These options could be pursued should this research proposal be carried out.
To ensure the protection of not only the data and information gathered but the participants of the study, various safeguards will be put in place. In relation to the data being collected, agency staff all sign confidentially and non-disclosure agreements as a part of employment requirement. As well staff gathering data will not have access to any results until the study is be completed. The collection and analysis of data is completed by an outside researcher to protect the integrity of the information as well as ensure there is no conflict of interest because of dual roles. Agency staff receive no personal benefit from completing the information collection as it is already a requirement of their position to complete WLM for waitlist clients. Each individual accessing services must sign an informed consent form which explains individuals rights regardless of participation in the study. Each participant is explained the study before they agree to participate. A participant can at any point withdraw from the study and it will not affect their wait time or ability to access services. As well each client is assigned a unique number which will be the only identification when the information is passed to the outside researcher.
This proposed study has numerous implications not only for mental health but also for Social Work as a profession. When looking at the micro level, the outcomes of this study could potentially provide increased services to those in the Lambton-Kent area involved with CMHA, reducing their wait time for service. This reduction would lead to faster access to services to help promote recovery while increasing quality of life. Looking at the mezzo level, the overall outcome of the study could provide valuable information to the Erie-St. Clair LHIN in effective and efficient resource allocation. This would in turn provide more funding to CMHA Lambton-Kent to increase the number of case managers on staff to address client needs. This information could also prove relevant to other LHIN’s in Ontario to address cost savings in their jurisdictions. Macro level implications could lead to a greater understanding of high cost health care users and inform health care planners in their efforts to improve quality of care in Ontario, reduce the cost of health care services and reduce the burden on patients and the overall healthcare system. Social work as a profession could also benefit as the components of the recovery model, which are practiced in case management, are very closely related to the values and ethics of the profession leading to further solidification that Social Work has a primary purpose and leading edge in the mental health field. This validates that Social Work is an important profession
Overall the proposed study focuses primarily on a small concentrated area of a specific population. While this could be harmful it does provide information to the area of Lambton Kent that is extremely beneficial and potentially cost reducing. As discussed previously the prevalence of mental health is not declining and the cost associated with this issue continues to grow. Being able to provide services to individuals with mental health needs as well as reducing overall healthcare cost is paramount and is a question that is currently circulating among health care professionals, funders and government. Having a solid understanding of what happens when these individuals are waiting provides the necessary information to show the importance of reduction of wait list times. As well provides a solution to take care of both the personal needs of those individuals as well as the economic needs of cost reduction. Information surrounding physical health services and needs are abundant; increasing the knowledge around mental health is just as important. Unfortunately operation of services is highly dependent on cost and this proposal would offer a dollar and cents value to help policy makers and funders make further funding decisions.
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