process and outcome generation in the UK700 trial Assessing the value of assertive outreach: Qualitative study of

Summaryof case studiesSummaryofcasestudies Standard casemanagementStandard case management Intensive case managementIntensive case managementAnyevidence casemanage-Anyevidence case manage- Evidence ofpositiveimpactin 7 cases.Key factors:Evidence of positive impact in 7 cases.Key factors: Evidence of positive impact in11cases.Key factors:Evidence ofpositiveimpactin11cases.Key factors:menthelped to avoid psychiatric emergencies?psychiatric emergencies?Provision of hostel place (nn¼2) or independent flat (nn¼1) and home support((nn¼1) through caremanager1) through care managerProvision of hostel place (nn¼6) through caremanagementThoroughmedicalreview (Thorough medicalreview (nn¼3)3)High commitmentof casemanager to practical and emotional support (High commitment of case manager to practical and emotional support (nn¼2)Case manager commitment to intensive practical help and emotional support (nn¼2)2)No evidence ofpositiveimpactin13cases.Key factors:No evidence of positive impact in13 cases. Key factors:No evidence of positive impact in 8 cases. Key factors:No evidence ofpositiveimpactin8cases.Key factors:Engagementandcompliancegood,butlimitedpotentialtopreventrelapse(Engagementandcompliancegood,butlimitedpotentialtopreventrelapse(nn¼5)Poorengagement(nn¼5),linkedtodiscontinuityofmanagement(5),linkedtodiscontinuityofmanagement(nn¼2)2)Engagementgood andrange of interventions described, butlimitedpotential to eliminateEngagementgood andrange of interventions described, butlimitedpotential to eliminate relapse (nn¼2)2)Patient extremely difficult to manage/non-compliantelusive (Patientextremelydifficult to manage/non-compliantelusive(nn¼3)Patientextremelydifficulttoengage/non-compliantorextremelyelusive(nn¼6)Any evidence emergencies weremanagedin such aweremanagedinsuchaEvidence of positive impact in 8 cases (including 4 cases where no admissionEvidence of positive impact in 8 cases (including 4 cases where no admission recorded).Key factors:recorded).Key factors:Evidenceofpositiveimpactin9cases(including4caseswithnoadmissionsduringstudyperiod). KeKeyyfacfatcotrosr:s:way that an admissionwasway that an admissionwas Highlevelof support from carer (High level of support fromcarer (nn¼2)orhostel(nn¼1) critical1) criticalTemporary increasein casemanagercontact (Temporaryincreaseincasemanagercontact (nn¼6)andrapidmedicalassessment(nn¼3)3)averted?Temporaryincreaseinintensityofcasemanagercontact+highlevelofpracticalsupport(Temporaryincreaseinintensityofcasemanagercontact+highlevelofpracticalsupport(nn¼1)1) High level support from carer or hostel critical, but outside case manager’s influence (High level support from carer or hostel critical, but outside case manager’s influence (nn¼2)Successful engagement ^ patient sought help from case manager during emergencies,Successful engagement ^ patient sought help from case manager during emergencies, not accident and emergency department (not accident andemergency department (nn¼1)Successful engagement.Patient sought help from case manager during emergencies, notSuccessful engagement.Patient sought help from case manager during emergencies, not accident andemergencydepartment (accident andemergency department (nn¼1)1)Care manager purchasedhome support (Care manager purchasedhome support (nn¼1)No evidence of positive impact in 6 cases. In 5 cases no emergency or admission wasNo evidence of positive impact in 6 cases.In 5 cases no emergency or admission wasNo evidence ofpositiveimpactin8cases(7 cases ^ 1ormoreadmission;1case ^No evidence ofpositiveimpactin 8cases (7cases ^ 1ormoreadmission; 1case ^ no emergencies or admissions recorded)recorded.Onepatienthadmultiple admissions andrejectedhostel places, which wererecorded.One patient hadmultiple admissions andrejectedhostelplaces, whichwere the only intervention likely to make community managementpossibleAny evidence admissions occurred when communityoccurred when communityAdmissions in15 cases.Evidence that emergencies, potentially manageable in community, led to admissionin10 of these cases.Key factors:community, led to admission in10 of these cases.Key factors:Admissions in10 cases.Evidence in 4 of these cases thatemergencies, potentially manageable inAdmissionsin10 cases.Evidencein 4 of these cases thatemergencies, potentiallymanageablein community, led to one ormore admissions.Key factors:community, led to one or more admissions. Key factors:management was possible?managementwaspossible? Breakdown of closemonitoringdue to casemanagerchange/temporarycover (Breakdownofclosemonitoringdue to casemanagerchange/temporarycover(nn¼4)4)Accident and emergency admission when casemanager unavailable (Accident and emergency admission whencase manager unavailable (nn¼3)3)Clinicallyinappropriate admission atrequestof hostel to‘manage’antisocialbehaviourClinically inappropriate admission atrequest of hostel to‘manage’antisocialbehaviour ((nn¼1)Delays establishing care plans/securing care manager involvement (Delays establishing care plans/securing care manager involvement (nn¼2)Breakdown of close monitoringdue to casemanager change/temporarycover (Breakdown of close monitoring due to case manager change/temporary cover (nn¼3)Clinically inappropriate admission to‘manage’antisocialbehaviour (Clinically inappropriate admission to‘manage’antisocialbehaviour (¼1)1)Any evidence of impact on the duration of admission?on the durationof admission?Admissions in15 cases.No case where significantpositive impact on duration ofAdmissionsin15 cases.No casewhere significantpositiveimpact ondurationof admission was attributed to activities of case managers.In 6 cases, factors wereadmissionwas attributed to activities of casemanagers.In 6 cases, factors were identified thathadnegativeimpact on admission duration.Keynegative factors:identified that had negative impact on admission duration.Key negative factors: Discharge delayed by slowness of care managementprocess: finding hostel placeDischarge delayedby slownessof care managementprocess:findinghostel place ((nn¼3), independent accommodation (3), independent accommodation (nn¼1) or organisinghome support (1) or organising home support (nn¼1)1)Delayed admission felt to have increased overall duration of admission (Delayed admission felt to have increased overall duration of admission (¼2)2)Admissions in10 cases.One casewhere casemanagers hadpositiveimpact on admissionAdmissionsin10 cases.One casewhere case managershadpositive impact on admission duration.Key factor: Developmentof careplan to admit earlyin relapse.Patientrecorded 4Development of careplan to admitearlyin relapse.Patientrecorded 4 admissions,withaggregateduration ofjust60 daysadmissions, with aggregate duration of just 60 days In 4 cases, factors wereidentified thathadnegative impact on admissionIn 4 cases, factors wereidentified that hadnegativeimpact on admission duration.Key factors: Discharge delayedby care managementprocess: findinghostelplacements (Discharge delayedbycaremanagementprocess: findinghostel placements (¼2)2)Delayed admission increased overall duration of admission (Delayed admission increased overall duration of admission (nn¼2)2)