The UK700 Group (2000) presents a comparative cost analysis of intensive case management (ICM) v. standard case management for patients with severe mental illness. It failed to find any significant difference in duration of in-patient treatment between the two groups at 2 years, and the cost of care was thus roughly equal. The authors conclude that “the policy of advocating intensive case management for all patients with severe psychosis is not supported….”.
While the execution of the UK700 study is admirable in terms of its sheer number of subjects, the design is critically restricted by the very nature of the ‘intensive case management’ offered. Indeed, the mean number of contacts per client was 100 (s.d.=64) v. 64 (s.d.=30) in the control group; this equates to around one visit per week and one per fortnight, respectively. Comparison with our local (ICM) service shows that our case managers visit clients far more regularly than this (daily, if necessary). While this might seem excessive, it appears that it is crucial to maintaining such patients in the community, and is ultimately cost-effective. Indeed, Preston & Fazio (Reference Preston and Fazio2000) showed that for our ICM service, with a capped case-load per case worker of around 10 patients, and a mean number of annual community contacts of 164 (s.d.=20) v. 56 (s.d.=100) for non-intensive patients, in-patient bed-days fell dramatically (from a mean of 118 days (s.d.=113) per year before ICM, to 57 days (s.d.=91) in the second year of the ICM intervention). The control group showed no such reduction in bed-days, and the overall cost saving (factoring in the increased out-patient costs for the ICM group) at the end of the 2 years was AU$801 475 for 65 patients (P <0.001).
Thus, it is important that the precise nature of the intervention is examined before dismissing ICM as a cost-effective model of service delivery.
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