Review Chapter 9, “Challenges and Visions.” Focus on the strategies described.

Week 6 Assignment

Application: Ending the Client/Case Manager Relationship

Celebrate endings, for they precede new beginnings.
–Jonathan Lockwood Huie

As they terminate their relationships with clients, case managers work to transition the focus from empowerment of clients through the use of resources to empowerment through reintegration. Reintegration with family, friends, community, and oneself can be a difficult process for clients. Enlisting clients in long-term services should be established prior to case management service termination.

For this Assignment, you consider ways in which you might terminate services with each of your virtual clients. What skills might you ensure that Charlene and James have before ending treatment? What agencies might you establish long-term goals with for Abigail, Robert, and Adam? To successfully terminate each case, you first evaluate the effectiveness of the treatments you provided for each client. You then develop comprehensive plans for the maintenance and termination of your cases.

To Prepare for this Assignment:

• Review Chapter 9, “Challenges and Visions.” Focus on the strategies described.
• Review the article, “The Quest for Optimal Health: Can Education and Training Cure What Ails Us?” Consider the implications described for “self-directed recovery.” during Week 4, in which you located resources and agencies in your community to find assistance for your clients.
• Review the article, “The Role of Self–Efficacy in Recovery From Serious Psychiatric Disabilities: A Qualitative Study With Fifteen Psychiatric Survivors.” Focus on the findings concerning the preparation of clients for recovery and reintegration.
• Consider the ways that your clients’ cases may have progressed.
• Think about how you might translate your clients’ experiences into the appropriate language for documentation.
• Think about how to terminate your cases based on the progress made by each client.

The Assignment (1 page)

• Develop a plan for the termination of case management services for your virtual clients.
• Explain one way the case management process has resulted in recovery, reintegration, or empowerment for your virtual clients.

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  International Journal of mental Health, vol. 37, no. 2, Summer 2008, pp. 69–88. © 2008 M.E. Sharpe, Inc. All rights reserved. ISSN 0020–7411/2008 $9.50 + 0.00. DOI 10.2753/IMH0020-7411370203

  Peggy Swarbrick, Dori S. HutcHinSon, anD kennetH gill

  The Quest for Optimal Health Can Education and Training Cure What Ails Us?

  ABSTRACT: This paper reviews the current need for training and education in the pursuit of optimal health for mental health consumers. recommendations for building the capacity of consumers and the mental and medical health-care systems to support the self-directed recovery of health by persons living with mental illness are made.

  Premature mortality, comorbidity of variety of serious medical comor- bidities, and ineffective treatment for persons with serious mental illness have been the enduring outcomes of the mental health system for over 30 years [1]. This is not a new crisis by any measure for people who live with a mental illness. Until recently, data has suggested that over 60 percent of individuals with mental illness develop serious medical

  Margaret (Peggy) Swarbrick, Ph.D. OTR, CPRP, is a postdoctoral fellow, National Institute on Disability and Rehabilitation Research (H133P050006), Department of Psychiatric Rehabilitation and Counseling, School of Health Related Professions, University of Medicine and Dentistry of New Jersey. Dori S. Hutchinson, Sc.D., is Director of Services, Center for Psychiatric Rehabilitation, Boston University. Ken- neth Gill, Ph.D., CPRP, is the chairman, Department of Psychiatric Rehabilitation and Counseling, School of Health Related Professions, University of Medicine and Dentistry of New Jersey.

  The views, opinions, and content of this publication are those of the authors and do not necessarily reflect the views, opinions, or policies of the Substance Abuse and Mental Health Services Administration or the U.S. Department of Health and Human Services.

   

   

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  comorbidities that result in a lost life span of 15–20 years compared with the general population [2]. Recently, even more alarming evidence indicates that in just the last decade, the risk for lost years of life has ac- celerated to 25 years earlier than the general population [3]. Anecdotal evidence suggests that not only persons receiving poor or psychiatric care are at increased risk for mortality from natural causes, but those receiving excellent and comprehensive psychiatric and psychosocial care are at increased risk as well.

  Compelling clinical and research data has emerged that documents how treatment medications prescribed to ameliorate the symptoms of mental illness induce a number of serious adverse health issues including the metabolic syndrome, diabetes, dyslipidemia, obesity, osteoporosis, periodontal disease, and sexual dysfunction [4–7]. Indeed, the Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) study found that those who take olanzapine are at increased risk for abnormal glucose and lipid metabolism compared to those taking conventional antipsy- chotics [8]. The CATIE findings also indicated that most individuals who develop these complications are not treated for them or are treated inadequately [9]. Rates of nontreatment ranged from 30.2 percent for diabetes, to 62.4 percent for hypertension, to 88.0 percent for dyslipi- demia. These findings support the need for “increased attention to basic monitoring and treatment of cardiovascular risk factors in this vulnerable and often underserved psychiatric population” [9, p. 15].

  It is indisputable that this staggering lack of a wellness lifestyle has been a powerful contributor to the disability experience and the recovery efforts of persons who live with mental illness [10]. The prevalence of being overweight, a smoker, and living a sedentary lifestyle is greater among people living with a mental illness (hereafter referred to as mental health consumers) compared to individuals without a mental illness. Lack of knowledge of correct dietary principles, lower self-efficacy, limited social support, and psychiatric symptoms influence health-related be- havior [11]. Functional outcomes—including employment, independent living, utilization of support services, hospitalization, and mental health service utilization—are negatively impacted by this elevated incidence of serious medical disease [12–13].

  This personal burden of illness represents a significant disparity in health care that must no longer be considered an inevitable de facto outcome of the mental illness experience. Mental health consumers

   

   

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  have a human right to optimal health, and the assertion of this right has significant implications for the mental health system, programs, provid- ers, consumers, and families [10]. Federal mandates are pressuring the mental health system to transform its approach to mental health care to ensure that services support the full recovery of mental health consumers, which includes an emphasis on health promotion and improved access to and interface of physical and mental health [14–18].

  Training and education of all stakeholder groups (i.e., consumers, families, and professionals) to promote health and reduce disparities in care is fundamental if we are to respond effectively to this crisis and promote the full recovery for mental health consumers.

  Current Education and Training Opportunities That Promote Health

  Professional training and consumer education are two distinct activities that can be used to disseminate knowledge and build capacity for specific behaviors. The lack of relevant training and education about health issues and health promotion are identified barriers that impede the achieve- ment of optimal health for mental health consumers [16]. The inability to transfer education and training into daily practices and lifestyles un- derlies these barriers and has long been recognized as the most difficult aspects of creating change and achieving desired outcomes. The lack of financial reimbursement strategies for health promotion services is also a formidable barrier that thwarts implementation of training, education, and health-care practices. These funding barriers are compounded by dif- fering staff training and philosophy, resource, and time constraints [19]. The consequences of these challenges have hindered recovery because people have experience unnecessary suffering, functional impairment, mortality, economic losses, and health-care costs [20].

  Health Promotion and Education for Consumers

  Despite these hurdles, there has been a growing recognition of the preva- lence of a mind–body duality assumption in the mental health system and the need to develop training and educational opportunities to address this fragmentation. There is an abundance of evidence-based research that demonstrates that people live longer and live well when they practice

   

   

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  healthy lifestyles and receive quality care [21–22]. The excess comorbidi- ties in people with serious mental illness are largely preventable health conditions that respond positively to educational interventions with diverse groups of people and in challenging environmental and cultural environments, indicating the potential for these strategies to be used in mental health [23].

  Mental health consumers strongly agree and use a variety of integra- tive and complementary health practices and treatments as they pursue improved well-being [24]. There is a growing repository of educational tools that address healthy lifestyles that reduce comorbidities. Health education and structured health interventions are currently available as resources to educate consumers to help them achieve improved health outcomes. In addition, peer-delivered health and wellness education curriculums have been widely implemented. For example, Kate Lorig and associates at the Patient Education and Research Center in Palo Alto, California, are developing, evaluating, and disseminating self- management programs for people living with chronic diseases, including arthritis, diabetes, and HIV/AIDS [25–26]. These programs are based on needs assessment, are peer led, and deal with medical, physical, and emotional components. These programs come in many formats including groups, Internet based, and mail delivered. These models are based on the notion that individuals can learn promote their own health, as well as contribute to the management of illnesses. Similarly, the Illness (also called Wellness) Management and Recovery Program for the manage- ment of serious psychiatric disorders is an evidenced-based practice that provides a standardized intervention that emphasizes skill development to help people cope more effectively with their psychiatric illnesses so they can pursue their recovery goals [27].

  Wellness and health promotion approaches for mental health practice have been proposed in recent years [10, 28–33]. Currently considered a promising practice, the Wellness Recovery Action Plan (WRAP) is an excellent example of a peer-delivered self-management tool designed to teach people to identify self-care strategies to maximize health [34]. WRAP is an educational self-management model that provides a structure to increase support and develop an action plan for both health and illness. This educational model prepares people to take responsibility for their health as a fundamental process of their personal recovery and wellness.

   

   

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  WRAP provides an excellent strategy to help people develop daily plans and other self-awareness processes to help restore personal wellness and recovery [31]. Translation of the WRAP is currently underway to allow its implementation into different Latino communities.

  Another peer-delivered educational self-management approach has been developed based on the National Wellness Institute dimensions of wellness, coaching principles, and peer support. This model is derived from the work of Travis and Ryan [22], Swarbrick [31–32], and Arolski [35] and is being offered in both community and hospital settings. Well- ness is defined as a lifestyle that includes a balance of self-defined health habits such as adequate sleep and rest, productivity, exercise, participation in meaningful activity, nutrition, productivity, social contact, and sup- portive relationships [31–32]. There is an emphasis on collaboration; the peer acts as a coach, helping to guide the person toward successful and long-lasting behavioral change. Peers apply principles and processes of professional life coaching to the goal of lifestyle improvement for higher levels of wellness [36].

  Heath promotion and education that includes the integration of physical activity, nutrition education, diet and glucose monitoring, dental health practices, smoking cessation, and HIV/AIDS education has a growing evidence base as effective practices that reduce morbidities that are largely preventable. Although not yet reimbursable as mental health services (some are reimbursable as “regular” health care), the effects of lifestyle education on chronic disease outcomes are large and consistent across multiple populations including serious mental illness [37]. Guidelines are available to assist in the provision of evidenced-based physical activity interventions that educate consumers and promote improved health [38]. Research has demonstrated that the response to physical activity among mental health consumers is very similar, if not more pronounced, than the response found among the general population. Physical activity not only has known health benefits regardless of illness type, but research has also documented that it can alleviate secondary symptoms such as low self-esteem and social withdrawal [39–40]. Physical activity programs that integrate education about the importance of activity as well as the sup- ported activity are recommended as education strengthens self-efficacy, which is one of the most important predictors of adherence to an active lifestyle [38]. Physical activity and educational interventions are feasible

   

   

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  and can result in significant behavior change, which improves the physi- cal health outcomes of people with serious mental illness. This type of education is critical in a recovery-oriented approach to mental health.

  Brown and Chan [41] reported on a brief health promotion interven- tion for persons living with mental illness. In a randomized controlled trial using a health promotion package, they produced small but statisti- cally significant gains in exercise and weight loss, as well as improved subjective well-being. Participants in this study had unhealthy lifestyles but were concerned about their health and interested in trying to improve it. Significant health gains were found.

  Tobacco use is a significant issue contributing to the poor health of con- sumers. Smoking cessation educational materials and intervention strategies have been shown to be effective. A manual for successful smoking cessation among persons with serious mental illness, Tobacco-free living in Psychi- atric settings, has been developed by Jill Williams and her colleagues at the National Association of Mental Health Program Directors [42].

  Behavioral approaches are effective in achieving a modest weight loss for people with psychiatric disabilities, which is associated with important health protective outcomes. Evidence-based food education assists people to manage their weight more effectively and counteract the ill effects of weight gain associated with lifestyle and medications [43–44]. These manualized rehabilitation interventions include goal set- ting, skills training, skills practice, and the provision of social support around nutrition that supports the recovery process. In addition, these curricula were adapted to compensate for any educational and cognitive impairment that people may experience.

  A dental health intervention that educates consumers on the impor- tance of oral health and teaches skills is essential to reduce comorbidity and mortality [45]. Psychiatric illness and the medications used to treat illness can cause oral complications and side effects including tooth decay, periodontal diseases, and excess salivation. Of concern is the fact that oral health and general health are closely associated, adding to the poor health burden of mental health consumers [46]. Oral health can be improved through consumer education programs that focus on dental education, dental instruction, and reminders [47].

  The National Alliance on Mental Illness has developed an educational program that targets comorbid physical health needs. Hearts and minds is a 13-minute inspirational video and a 26-page booklet. The purpose of the program is to raise awareness and provide information on diabetes,

   

   

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  diet, exercise, and smoking. The program also includes basic information on addictions, recovery, stigma, and treatment. Along with information on diabetes and sleep apnea, Hearts and minds contains tips for exercise, diet and includes a shopping list template, recipes, and a food diary.1

  Recommendations

  Recommendation 1: Including Health Promotion in Curricula and Training Experiences of All Providers

  It is clear that health promotion should be included in the training cur- riculum and training experiences of all providers. The President’s New Freedom Commission [18] noted that serious problems in the education and training of mental health providers exist that contribute to problems in both access to and quality of care for persons with serious mental illness. Treatment of persons with mental illness has traditionally come from a pathological orientation. This approach to treatment, which often begins with professional education, is further ingrained by stereotypical beliefs and attitudes toward persons living with a psychiatric disability as being sick, incapable, and dependent. The incorporation of health promotion practices and philosophy into mental health service provision complements the recovery vision of the mental health system. Profes- sional education that incorporates health promotion principles, health knowledge, skills, and strategies is necessary in the transformation of the system to one that supports recovery [10]. The President’s New Freedom report [18] stated that university training programs responsible for the education of mental health-care providers must adapt to meet the needs of persons living with a psychiatric disability. Recently, the Annapolis Coalition reports concluded similarly [48]. Therefore, educa- tional, behavioral, and cultural approaches that promote health must be essential components of provider education [49–50]. Specific skills and knowledge that are essential for all professionals working with people living with mental illness on their health issues include active teaching skills; consultation skills; communication skills including shared deci- sion making, information sharing, and partnering; cultural competency skills; and trauma-informed health knowledge as well as basic health literacy skills [14, 51–52].

  A vast literature base documents the importance and positive of ef- fective communication skills between a person and a provider on health

   

   

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  outcomes. Active participation in one’s health-care leads to greater satisfaction, relevant treatment, and better health outcomes. Working within a health framework, rather than an illness framework, providers need the tools to support change not only in people’s mental health but also in their lifestyle choices that contribute to illness, functional health, subjective well-being and perceived quality of life.

  Recommendation 2: Educate Medical and Allied Health Professionals in Working Collaboratively with Persons Diagnosed with Mental Illness

  Educating all medical and allied professionals to work collaboratively and share decisions with mental health consumers and assist them to self-direct their health is critical. Many medical and dental providers indicate they lack the knowledge to assess and respond effectively to mental health consum- ers. Collaborative care models that integrate interdisciplinary care have developed academic programs that educate psychiatrists to recognize and treat medical disorders as well as programs that train primary care physi- cians to recognize and treat psychiatric disorders. Approximately 40 dual training programs exist that educate physicians to become board eligible in psychiatry and a primary care specialty. Unfortunately, the translation of this integrated health education into daily medical practice has been limited.

  Currently, the education that many mental health staff receives does not adequately prepare them to collaborate with mental health consum- ers to help them reduce their comorbidities and prevent premature death. Providers need communication skills. Many providers lack the awareness and knowledge of health-care problems in people with mental illness. In addition, many providers may struggle with similar health issues them- selves such as smoking, obesity, and unhealthy lifestyle habits and may not have yet mastered their own skills in managing their health.

  Recommendation 3: Primary Care Physicians Need More Education on Psychiatric Disorders

  Primary health physicians need enhanced education about the conflu- ence of psychiatric disorders and health issues—especially given that 40 percent of patients treated by primary care physicians have signifi- cant mental health problems and only about one-half of these receive mental health care, usually by the primary care physicians themselves

   

   

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  [53]. Indeed, there is an extensive literature published over five decades identifying a strong need for ongoing mental health training for primary care physicians [54]. Recently, there has been an increased attempt to incorporate psychiatry in primary care training programs. Directors of 1,365 accredited residency training programs in internal medicine, fam- ily practice, obstetrics/gynecology, and pediatrics received a 16-item anonymous questionnaire focused on descriptive data concerning their psychiatry training. A majority of primary care training programs are dissatisfied with the current status of their psychiatric training (except for family practice programs, which have the most variety in training formats, locations, and teachers). The majority of primary care training programs desire more training in all aspects of psychiatry [53, 55]. More attention to education on psychiatric illnesses is critical in the preparation of primary care physicians.

  Recommendation 4: Professional Training of Psychiatrists and Others with Prescriptive Privileges Must Include Training in Metabolic Syndrome and Other Common Side Effect Profiles

  The strong association of both conventional and second generation antip- sychotic medications with obesity and related conditions such as diabetes, hypertension, and other metabolic syndrome disorders must become cen- tral to the consciousness of prescribing antipsychotic medication, just as motor side effects and tardive dyskinesia have previously become central considerations. Thus, at the very onset of prescribing these medications, weight, glucose, and lipid monitoring should commence, as should preven- tive measures in diet and exercise that will reduce the risk of obesity. This practice is not yet standard. It has been recommended that psychiatrists complete residencies not only in psychiatry but also family practice or internal medicine, considering the high likelihood of psychotropic side effects compromising other bodily systems. Later, board certification on psychiatry and one of these other areas should also be sought.

  Recommendation 5: Allied Health Professionals Need Training on Psychiatric Disorders and Communication Skills

  Not only do psychiatrists, primary care physicians, and advance practice nurses have a role in integrating the primary and psychiatric care of

   

   

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  mental health consumers, but also many other allied health professionals have a role, including nutritionists, dieticians, physical and occupational therapists, dentists, and dental hygienists. There is little published specifi- cally on training of the professionals in psychiatry (for a review, see [56]). Yet, they need to know something of diagnoses, course, and outcomes of serious mental illnesses and the role of side effects in the lives of mental health consumers. See Table 1 for a summary of critical health tips for health-care professionals about mental illness, antipsychotic medication, and overall health. These professionals need education about diagnoses and communication skills. Spagnolo and Murphy [56] asserted that all health care professionals may face communication challenges with mental health consumers, including difficulty describing symptoms. There may be a tendency to overattribute vague or abstract descriptions to the disorder or “somatization” a delusional symptom. This tendency needs to be counter- acted. Spagnolo and Murphy [57] have developed an on-line course and a DVD, Innovative strategies in the Health Care of Persons with Psychiatric Disabilities, to help professionals build skills in this area.

  Recommendation 6: All Professionals Need to Understand the Importance of Self-Management Models

  Certainly, there is ample evidence that persons without mental illness can contribute to the successful self-management of their diabetes and related disorders. Both allied and mental health professionals need to avoid the trap of pessimism regarding outcomes for mental health consumers. These professionals need education to understand the widespread evidence of the likelihood of successful recovery. In addition, there are reasons to believe that mental health consumers can profit from dietary and exercise interventions in terms of weight loss and improved glucose levels [41, 44]. The current movement to promote the evidence practice of illness manage- ment should include wellness management of obesity and the metabolic syndrome. All professionals need to understand the effectiveness of illness and wellness self-management principles and practices.

  Recommendations 7: Education and Training Practices Based on Psychiatric Principles to Promote Wellness

  Psychiatric rehabilitation education, peer-delivered models, and mentor- ing/coaching are opportunities for providers to learn the essential skills

   

   

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  of working collaboratively as a partner with people in their personal health and recovery. Psychiatric rehabilitation principles and practices acknowledge the individuality of people with psychiatric disabilities, their unique health needs, personal goals, and their capacity for self- determining their own health promotion activities [10]. Health promo- tion principles state that health education is the cornerstone for health promotion and prevention for mental health consumers (see Table 2). These principles are grounded in the fact that people recover and that people need functional health as a foundation for their recovery [10]. Professional development in psychiatric rehabilitation that focuses on these health values, principles, knowledge, and skills is available through

  Table 1 Critical Health Tips for Health Care Professional about Mental Illness, antipsychotic Medication, and Overall Health

  • Regular use of antipsychotic medication, use of multiple versions of antipsychotic medication is associated with obesity, the metabolic syndrome, circulatory and cardiac complications, and thus premature mortality of 15–25 years compared to persons with mental illness [58–59].

  • These side effects are associated with both conventional antipsychotic medica- tion and second generation medications, with risks of mortality four times greater than that of the general population for traditional antipsychotic medication, five times greater for second generation medicines [7].

  • Metabolic disorders such as diabetes, hyperlipidemia and hypertension are highly prevalent in populations with schizophrenia, exceeding 50% in some stud- ies [9]. A total of 30%–88% of these individuals, depending on the disease, are not treated at all for these disorders [9].

  • These metabolic syndrome disorders are best conceived of as also circulatory and cardio-vascular disorders.

  • Coordination of psychiatric and medical care cannot be left to chance or simple referrals without follow-up.

  • Other side effects can include motor symptoms including tardive dyskinesia (pri- marily conventional antipsychotics) [8] and dry mouth, resulting in serious dental problems.

  • Pharmacological interventions for these metabolic syndrome disorders are ef- fective, as are behavioral methods (such as self-monitoring of glucose levels by people with diabetes). When these diseases are well-managed, individuals with these disorders suffer minimal