A Comparative Evaluation of Three Intensive Case Management Services for the Severely Mentally Ill:
Jeanette M. Jerrell, Ph.D., Director of Research
Rex S. Green, Ph.D. Evaluation Research Specialist
Santa Clara County Mental Health Services Research Center
Santa Clara County Mental Health Bureau
Bob Martinez, Director
Summary: It is certain that severely mentally ill adults with high levels of need for services can be managed and treated most effectively using intensive case management programs. These programs clearly reduce the total direct care costs for clients over time and improve client functioning in the community as well. These findings indicate that expansion of these case management services will result in substantial savings to the County mental health system while improving client outcome.
The Mental Health Bureau has been evaluating the relative cost-effectiveness of three of its intensive case management programs which specifically target their services to adults who are severely and persistently mentally ill and are high users of the acute and subacute treatment services. These clients have two or more inpatient or skilled nursing facility episodes during the year prior to their entry into one of these three case management programs, as well as being noncompliant with previous outpatient services, being conserved and receiving SSI payments. the three case management programs are: Virginia Street Project, Community Companions, and Downtown Mental Health Center. Each program offers clients a different mix of outpatient, medication, case management, housing, and supportive day services, depending on their service philosophy and their caseload size.
Overall, the three intensive case management programs currently serving severely and persistently mentally ill adults are substantially reducing the direct service costs for these clients and improving their psychosocial functioning in the majority of clients served. Our data also indicate that these reductions in direct mental health service costs do not increase the burden on families or other social/criminal justice services. However, there are differences among the three programs in the degree to which they are lowering direct service costs and increasing client functioning. The relative cost-effectiveness of the three programs depends on which outcome (treatment cost reductions versus client improvement) is considered.
The most cost-effective service from both of these perspectives is the Virginia Street Project which is reducing the total cost of mental health services to its clients by about $14,000 per year, compared to the level of care they required prior to receiving this service. the greatest reduction is in the inpatient days and skilled nursing facility days of service used (see Figure 1).
They are also providing significantly more supportive outpatient and case management services to these clients (see Figure 2), but these services are offered at only a fraction of the cost of acute and subacute treatment facility costs. Client functioning is improving to the greatest extent among VSP clients as well (see Figure 3).
Clients served by Community Companions demonstrate the next greatest improvement (see Figure 3) in functioning, and their total treatment costs are reduced $5,000 per client per year, the first year they are provided intensive case management services. This outcome seems consonant with Companion's program philosophy which emphasizes client empowerment and rehabilitation as well as compliance with taking medications and explicit avoidance of hospitalization.
Downtown Mental Health Center clients showed reduced annual direct treatment costs of about $7,800, per client per year. Client functioning improved less in the first year than for the other two programs, although Downtown MHC clients demonstrated the same pattern of overall change as the clients in VSP or Companions (Figure 3). These outcomes seem consistent with the program's emphasis on maintaining clients in the community by providing supportive outpatient counseling and medications and with staff caseloads being twice the size of those at VSP or Community Companions during this study.