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The case for case management

Editor’s Note: EdNC has invited the National Alliance on Mental Illness(NAMI)-NC to be a regular contributor. According to the state’s estimates of prevalence of mental illness, developmental disabilities, and substance abuse, 1.4 million people across North Carolina need mental health care – about 14% of the state’s population. Of those, almost 340,000 are children. EdNC will be exploring the role of public schools in making sure these children have access to the services they need to have access to a high-quality education.

 “For young adults with a mental health issue, and especially for their parents, turning 18 is scary. These kids are not equipped to cope with the stress and pressure of being adults. Too many students are lost in transition.
– Julie Jarrell Bailey, mother and advocate

We have tried so very many things over the past decade to make sure those with mental illness receive the services they need to recover. But we need to learn lessons from things that did not work and apply them as we go forward. A couple of years ago one of those trials was to get rid of case management, probably because the billing was just too high. Case management is a service that links people to the services they need. What we’ve done of course is to increase the complexity of our service system exponentially through privatization. Gone is the time when everyone in their community knew where to find their mental health center. Now, most services are run separately by different agencies, so from the point of view of the person needing services, there is lots of shopping around in a very complex health care environment. And we ask people with thought disorders, who can’t think clearly always, to figure out this system. Names change, players change. Yet we got rid of the “navigator” system just when we made it so much more difficult to, well, navigate.

Children and families who have a child with a serious mental illness don’t have access to case management either unless it is bundled within a service.

It is time to restore case management. Should it be exactly as it used to be? Definitely not. We must build it in a way that it is once again not a spiraling out of control budget item. And we can do that: we can define case management around targets. Using common sense as a guideline, we know there are times from our own lives and health care experiences when you need more help: after a hospitalization, during a transition such as aging out of school, or moving from a group home to a home of your own, or doing an acute episode of illness such as a psychiatric crisis. You need case management when things change, or when they need to change, and it needs to phase out. The only adults right now who are lucky enough to get this essential service are those who happen to get services from an Assertive Community Treatment Team (ACTT), Community Support Team (which no one really uses), or from psychosocial rehabilitation services (clubhouses) that tend to do everything that the person needs, even without the opportunity to bill to cover their costs. Children and families who have a child with a serious mental illness don’t have access to case management either unless it is bundled within a service. This is such a crucial time for services, as evidence points to half of all lifetime cases of mental illness beginning by age fourteen.

And let’s not say that we can’t afford to add another service to our array. Truly, we can’t afford not to offer this service in our array. Individuals exiting the prison system (far too many have mental illness and fail to adjust) could benefit from targeted case management to connect them to the community and help them rebuild their lives. Individuals who now land in the emergency departments might not have landed there if case management instead helped connect them to services that helped them stay stable and in recovery. We spend so much more money on these emergency interventions than we ever would with a little case management applied in just the right dose and at the right time. 

Need more reasons to restore case management? Here’s what the Department of Justice had to say about it when we were called out:“The State will rely on the following community mental health services to satisfy the requirements of this Agreement: … case management…” It’s on the list of what we must do. Let’s just do it. Let’s learn from our past.

Read a mother’s personal lessons about the need for effective case management.

Deby Dihoff

Deby Dihoff, MA, is the previous executive director of the National Alliance on Mental Illness (NAMI) NC.