Evaluation CM | Davor Zovko

Educating the weavers and building the looms at the same time

Evaluation of the Case Management method implementation in three Counties in Sweden

Mats Ekermo

Davor Zovko

Cover of the Report from Evaluation of Cae Management, published by Mälardalen University

In spring 2005 the Swedish Association of Local Authorities and Regions (SKL) opened a possibility for the country’s municipalities and counties to express interest to participate in a method development work. The development work was focused on the group of people with severe mental problems and drug abuses, dual diagnosis or comorbidity. The method that was introduced was the Case Management, a team-based treatment model with a so-called Case Manager (CM) as a spider in the web. Participating counties and municipalities were offered training, guidance and support in implementation of the new approach. A large number of expressions of interest were received. The selection process that followed resulted in the fact that three counties with collaborating municipalities became part of the project: Norrbotten, Jönköping, and Västra Götaland / Sjuhärad. Method development work started in September 2005 and lasted until the end of 2006.

The evaluation of SKL-project was carried out in two steps. This report summarizes the process and results achieved up to the end of 2006. In April 2008, a final report that includes a follow-up study a year later, will be presented. The evaluation was conducted by researchers at Mälardalen evalua-tions academy of Mälardalen University: Mats Ekermo, PhD in social work and Davor Zovko, MA in Education. The evaluation is based on a wide material collected through questionnaires and interviews with participating players in the project, focus groups, participant observation, study of documents, evidence and grading works and client interviews. In addition to theories on Case Management, the theory perspective of this evaluation is completed with the Implementation theory and the Program theory.

The idea for the title of the report ”Educating the weavers and building the looms at the same time” is taken from a participant who has undergone training in Case Management, a 10-credit contract training given by Växjö University under the project. The evaluation shows that the method development work is a complex process involving a large number of parts that must be in place before the actual work with Case Management can begin. Weaver in the metaphor represents a CM and the loom of the surrounding organizational support structure as the so-called ACT model of case management requires. This support structure involves close collaboration between organizations: counties, municipalities, psychiatry, social services, primary care, outpatient care, insurance and others. The ACT model includes a multi-disciplinary team of psychiatric, medical and social expertise. They play a primary role and function as support for the CM’s work.

Through the project, information, training and supervisional activities, the participating municipalities and counties have achieved knowledge of the Case Management. The evaluation shows that this is particularly case with the approx. twenty participants: psychiatric nurses, social workers, therapy assistants, occupational therapists and others who attended a higher rate. Higher up in the organizations, particularly at middle management level and, there is still more to do in terms of achieving the knowledge and understanding, as well as anchoring of the Case Management in the organizations.

The evaluation shows that the primary teams were in place to varying degrees (in different areas) and that the working conditions for Case Managers vary between the participating municipalities and counties. Among other things, the size of the municipality is playing the role as well as the extent to which psychiatry, primary and dependent care, are developed. This affects the ability to obtain specialist skills to the primary teams.

Signing agreements between cooperating organizations, in which roles and responsibilities are clarified in order to secure long-term commitments in the method development. The evaluation shows that verbal agreements and intentions at the policy level exist and that action plans are being developed in some areas, but no binding agreement has been realized during the project period, with some exceptions. Nor have any regularly conducted client surveys been carried out, with some exceptions, where the number of clients with severe mental disorders and concurrent substance abuse, have been identified.

Client study shows that people with mental health problems and concurrent substance abuse have a difficult life situation. This provides a strong argument for the SKL’s methodological work. Due to fact that the Case Management method is under implementation, the clients have limited experience of the new approach. Clients, however, are cerefully optimistic for this new method, on the basis of of what they have experienced so far.

The evaluation notes that SKL method development work has a long-term aim. SKL wants the project to contribute to methodological development in municipalities with focus on the target group of people with severe mental disorders and concurrent substance abuse. The evaluation shows so far that the CMs have been trained, they know what method of case management is about, and they want to apply it, but cannot. The project has initiated a number of local development processes. These require continued support to the weavers in order to make them able to do the jobs they are now trained for, namely that the looms are to be completed and put in the place.

A broader issue that is interesting to discuss, with the support of experiences of the SKL-project, is the possibility to implement an American big-city model, Case Management, in a Swedish context. There are research studies that show that Case Management according to the ACT, has an evidence-based support in the work with people with mental health problems and concurrent substance abuse. How successful are the seriously meant implementation trials in Sweden? The Evaluation regards the implementation as a translation process in which an idea is transferred from one context to another, undergoing reinterpretation and adaptation to local circumstances. What is the result, which local models have been developed and how can we understand the deviations from the basic model? These are questions that will be discussed further in the final report in spring 2008.

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