Background Studies of intensive case management (ICM) for patients with psychotic illnesses have produced conflicting results in terms of outcome. Negative results have sometimes been attributed to a failure to delive...
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Background Studies of intensive case management (ICM) for patients with psychotic illnesses have produced conflicting results in terms of outcome. Negative results have sometimes been attributed to a failure to deliver differing patterns of care. Aims To test whether the actual care delivered in a randomised clinical trial of ICM v. standard case management (the UK700 trial) differed significantly. Method Data on 545 patients' care were collected over 2 years. All patient contacts and all other patient-centred interventions (e.g. telephone calls, carer contacts) of over 15 minutes were prospectively recorded. Rates and distributions of these interventions were compared. Results Contact frequency was more than doubled in the ICM group. There were proportionately more failed contacts and carer contacts but-there was no difference in the average length of individual contacts or the proportion of contacts in the patients' homes. Conclusions The failure to demonstrate outcome differences in the UK700 study is not due to a failure to vary the treatment process. UK standard care con-rains many of the characteristics of assertive outreach services and differences in outcome may require that greater attention be paid to delivering evidence-based interventions;Declaration of interest None.
[...]those in the intensive management service also received a brief course of training in the Boulder Community Support System (CSS) model of care; this shows similarities with assertive community treatment (ACT) pra...
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[...]those in the intensive management service also received a brief course of training in the Boulder Community Support System (CSS) model of care; this shows similarities with assertive community treatment (ACT) practised elsewhere in the USA (Stein & Santos, 1998, p. 33).
The main question the findings pose is why the greater frequency of contact in ICM was not translated into any clinical improvement with regard to either the primary outcome (duration of in-patient psychiatric treatment during the study) or a range of secondary outcomes, including the specific one that improvement with ICM might be more effective in those of African-Caribbean ethnicity (UK700 Group, 1999a ).
Assertive community treatment comprises six essential features: case-loads of no fewer than 8 and no more than 12 per keyworker, an integrated team structure with at least three professional disciplines, no more than 20% of staff part-time, 24-hour availability, team autonomy and (an important consideration) part-time psychiatrist input only (Stein & Santos, 1998, pp. 64-65).
The presence of 24-hour cover is also not as important in the UK as in the USA.
Because there is often no real health cover available for these patients in the USA it is easy to see why it was necessary to set up a telephone contact system.
Observations on ward rounds suggested that psychiatric patients might be at special risk of removal from their general practitioner's list. Little has been published on why patients are struck off and our first at...
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Observations on ward rounds suggested that psychiatric patients might be at special risk of removal from their general practitioner's list. Little has been published on why patients are struck off and our first attempt at investigation was by direct appeals for patients. This drew a small and unsatisfactory sample. We then asked two family health services authorities to distribute questionnaires to struck-off patients. One agreed, but later withdrew cooperation. There is a danger that struck-off patients will become an underclass excluded from primary care. We propose anonymous collection of information by health authorities, so that policy can be reviewed if necessary.
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