The U. S. Department of Veterans Affairs Mental Health Intensive Case Management (MHICM) programs are evidence-based, intensive clinical case management programs that provide community-based support services to Veterans who have serious mental illnesses (SMI).

MHICM programs provide mental health case management services to Veterans with SMI, primarily those with diagnoses of psychotic disorders such as schizophrenia, schizoaffective disorder and bipolar disorder. Other diagnostic groups are considered based on clinical appropriateness for case management. Veterans can receive their outpatient mental health services in MHICM on a time-limited basis or indefinitely, based on clinical needs as well as personal preference. The majority of MHICM Veterans are in the program for many years.

Twenty three years ago MHICM programs were “hospitals without walls.” Today these intensive clinical case management programs include advocates, life coaches, managers, administrative assistants and therapists. The uniqueness of the approach lies in the application of the principles of psychosocial rehabilitation in real-world settings. Veterans and staff can be seen walking side by side looking for housing, shopping for furniture, developing budgets, negotiating with landlords, meeting neighbors, and taking public transportation to learn their way around a new neighborhood.

From Past to Present

Born from the challenges of meeting the unique needs of Veterans with serious and persistent mental illness who experienced repeated inpatient hospitalizations and were unable to successfully utilize traditional outpatient services, in 1987 the VA initiated a 10-site demonstration project to evaluate the effectiveness of assertive community treatment models of care. The demonstration project was evaluated by the Northeast Program Evaluation Center (NEPEC) in West Haven, Conn. Some programs were designed after the Assertive Community Treatment (ACT) model, an evidence-based model shown to be effective in helping people with SMI live successfully in the community. ACT began in the late 1960s, initiated by pioneers Dr. Arnold Max, Dr. Leonard Stein and Dr. Mary Ann Test. This model was adapted for MHICM programs and is currently used throughout the country at 111 VA locations.

The pilot projects demonstrated that MHICM was effective in both reducing use of inpatient hospital days and improving quality of life, according to research published in the Archives of General Psychiatry. Data has shown a decrease in inpatient hospital days and improvement in clinical outcome measures such as overall functioning (Global Assessment of Functioning Scale), symptom severity, community-living skills, quality of life, and patient satisfaction with services (NEPEC MHICM National Performance Monitoring Reports 2000-2008).

MHICM programs utilize the Assertive Community Treatment Fidelity Scale and the MHICM Team Implementation Checklist to guide program operations to ensure that programs target the SMI population and provide intensive, community-based case management services. Programs that maintain fidelity to these guidelines have the most successful clinical outcomes. Continuous outcome monitoring by NEPEC has provided ongoing feedback for service improvement, which has facilitated a shift in service provision from an early goal of stabilization to one of psychosocial rehabilitation and recovery. People with serious mental illness can and do live full lives in spite of their illnesses.

Therapy occurs as issues arise in the context of daily living, and problem solving occurs in the very environment in which it arises. The emphasis is on recovery and rehabilitation—and learning how to live with a chronic illness while building a life in the community. Veterans with SMI have the same goals as everyone else—a home, job, supportive relationships, life contributor, meaningful life activities. MHICM programs provide the traditional treatment services, including individual, group and family therapy; medication management; crisis intervention services; psychoeducation; illness management; and referrals to other health services. At the same time, MHICM staff work with Veterans to identify and realize their life goals—exploring housing options, money management, shopping, negotiating conflicts, developing social supports, exploring work and leisure activities, and activities of daily living are all part of the MHICM domain.

Defining Core Elements

There are four core elements to the MHICM model:

1. Intensity of Contacts. MHICM has a low staff-to-Veteran ratio to ensure Veterans are seen as often as clinically appropriate. Contacts will change in frequency depending on the clinical need of the Veteran, and can be once to five times a week, with the average of three times a week.
2. Flexibility and Community Orientation. Most clinical services are delivered in-vivo, where the Veterans live and where the most clinical leverage can be obtained. This includes the full range of case management services, mental health therapies, crisis intervention and medication management, among others services.
3. Rehabilitation Focus. Emphasis is placed on practical problem solving and helping Veterans obtain the life components they need to live successfully in community settings of their choice. This does not mean there is always full agreement between Veterans and the MHICM treatment team; however, maximum independence for each Veteran is desired, with the focus on the Veteran’s identified goals.
4. Continuity of Care. MHICM teams are comprised of multi/inter-disciplinary treatment teams that function as the hub of the treatment. The MHICM team is the fixed point of clinical responsibility, serving as the primary providers of outpatient mental healthcare, coordinating the many services provided to Veterans. It is holistic in the approach, and medical as well as mental health oversight is part of the work.

One of the integral components of the work in MHICM is the interaction and functioning of the team. A team of professionals (e.g., nurses, social workers, psychiatrists, psychologists) and paraprofessional staff (e.g., social work representatives, psychology technicians, certified peer specialists) provide the case management services. Each staff member brings unique skills and interest to the team and draws from other staff to enhance their work with Veterans.

Regardless of discipline, all team members work on facilitating the identified comprehensive treatment needs. As such, nurses will assist Veterans in obtaining benefits or identifying housing options, and similarly the social work staff will arrange and accompany a veteran to a medical appointment. Certified peer specialists are not primary case managers; however, they work as full members of the treatment team and help to facilitate the goals of Veterans, representing hope that life goals can be attained, and exemplify the very concept of recovery and rehabilitation.

Additionally, supported employment specialists are embedded on many MHICM teams. Every Veteran who expresses the desire to work is accepted into what’s known as the supported employment program, and competitive community jobs are negotiated based on the Veteran’s interests and abilities. By being embedded on the team, the supported employment specialist is aware of clinical state changes and can adjust employment support accordingly. This maximizes success in identifying problems early on, allowing for early employment interventions and successfully maintaining jobs for Veterans.

Case Study

Mr. Smith is a 60-year-old long-term MHICM patient, admitted some 20 years ago after a year-long hospitalization. At baseline he suffers from chronic psychotic symptoms in the form of auditory hallucinations, persistent paranoid delusions and chronic suicidality. He was initially living with his family, and work began with home visits with Mr. Smith and his family. His parents had always believed that he was “lazy and did not want to work.” The initial focus of the team centered on education about his illness, symptoms, medication compliance and how to balance independence.

Obtaining the family’s support through this educational process was crucial in Mr. Smith’s psychiatric stability. MHICM helped him become involved in outside activities and he started volunteering at an animal shelter. MHICM staff walked side by side with Mr. Smith when both of his parents died, shifting the work to grieving and redefining his role of living alone.

Concrete skills were modeled and practiced in areas of household maintenance, budgeting and assuming responsibility for his own healthcare needs in a more proactive way. As the house fell into disrepair and it became apparent he could not manage his own finances after he used his funds to make extravagant purchases, he agreed to move from his family residence, allowing management of his sizable estate to a conservator.

He moved to an intermediate care facility where he often talked about suicidality. Residential staff would send him to the hospital for evaluation, frightened of both his persistent psychotic symptoms and for his safety. Working with both Mr. Smith and the residence staff, MHICM professionals helped them understand his unique illness and together designed coping strategies and concrete tools to more successfully manage day-to-day life.

After a period of stability Mr. Smith wanted to move to a less restrictive environment. MHICM explored options by visiting several housing alternatives and the patient chose a board and care facility. While living there he developed diabetes. A collaborative effort coordinated by MHICM between medical providers, MHICM psychiatrists, residence staff and the patient helped ensure appropriate medication and dietary changes, while maintaining the patient’s psychiatric stability. With stable housing and good health, Mr. Smith was able to explore work opportunities.

With the support of an employment specialist, he found work at a local pet store and was able to create a tailored work schedule. Periodically he did not show up for work, which was often related to feeling more paranoid or voices telling him not to go. A plan to call the supported employment specialist and MHICM team to talk through his symptoms led to more consistency at work. With the addition of ongoing support from an MHICM peer support specialist, with whom he could share his personal journey of recovery, Mr. Smith increased his work hours and now identifies a greater sense of self-worth and a feeling of contribution as the rewards of work.

To date, Mr. Smith lives in a board and care, and while he struggles with chronic symptoms he enjoys a job, maintains social supports in the form of friendships and relationships with family, has available funds for his leisure activities and is in good physical health. Mr. Smith is able to say he enjoys life.
In summary, it is rewarding to know that the case management services, support and guidance Veterans with SMI receive through MHICM improves the health and quality of their lives. Having access to continuous monitoring and feedback through NEPEC allows MHICM programs to refine services to meet the changing needs of these Veterans. MHICM programs truly aid Veterans with SMI to walk the road of recovery, and in the process MHICM staff and Veterans alike learn and grow.