Review your own profession’s code of professional ethics and think about issues about which you have a strong moral belief.
• How would you manage a situation in which your moral code and professional code differed?
• What would be an example of this situation for you?
READ: Meadows (2012) pp 47-49 discussing the Ethical Underpinnings of Health Care Delivery
Last modified: Wednesday, 25 February 2015, 12:20 PM
• 9. Managing comorbidity and complex casesPage
9. Managing comorbidity and complex cases
Mental health issues do not occur in isolation. Mental illness occurs within a context, and the level of complexity can often be overwhelming.
When managing cases of co-morbidity, it is important to begin with a thorough assessment of the consumer (Meadows et al, 2012).
When conducting this initial assessment it is important to paint a full picture of the consumer and their experiences in context. It is also important to get an appreciation of the relationship between different issues the consumer faces. For example, if a consumer has alcohol dependence and a problematic relationship with their partner, it is important to establish how the two are connected. Does the consumer drink to cope with the stress of the relationship, or does the consumer’s drinking cause the relationship breakdown? Once a fuller picture of the consumer is determined, it is then possible to begin to address each issue based on your greater understanding of the consumer’s situation as a whole.
Multiple agency involvement
When managing complex cases there is more often than not the need for more than one agency to be involved. When working with cases involving multiple agencies it is important to consider the following practical measures to ensure the best outcomes for consumers:
• Designate a lead agency: When providing collaborative interventions a lead agency or worker should be identified to perform coordination tasks such as convening case conferences and handling management of the overall treatment.
• Communication: The lead agency or worker should ensure that appropriate permissions are gained for agencies to share information regarding the consumer with other workers involved in providing care. This establishes a culture of openness and transparency and prevents consumers from shopping between workers for desired outcomes.
• Case conference: Before any treatment begins it is important to facilitate a case conference involving all concerned parties, including the consumer (although the consumer may be present for only a part of the meeting). During the conference, attention should be given to the following matters:
o Clearly defining roles and responsibilities of all parties.
o Outlining treatment goals.
o Establishing communication protocols.
o Developing a shared understanding of the consumer and the interventions needed.
o Determining time frames for intervention.
o Setting up review dates for further case conferences (Arkowitz et al, 2008).
One of the disadvantages of multiple agency involvement is that differences between agencies (for example, in areas such as underlying philosophy and staff skill levels) can often lead to consumers receiving mixed messages, which in turn can negatively impact on consumer outcomes (Arkowitz et al, 2008). The alternative is to provide integrated care: that is, that one agency works to meet all the major needs of the consumer simultaneously. Whilst this method of working is not always possible, it does have these advantages (Arkowitz et al, 2008):
• It reduces the complexity of arranging care.
• It reduces the burden on consumers to attend multiple appointments.
• It simplifies the messages being given to consumers.
• It assists with consumer engagement by reducing the number of people consumers need to engage with.
• It reduces the time burden on services by eliminating the need to coordinate communication across agencies.
Providing integrated care within mental health treatment involves clinicians using therapeutic exchanges to address multiple issues. For example, whilst providing psychoeducation on mental health diagnosis, the clinician can speak about the effect substance misuse can have on illness progression (Arkowitz et al, 2008). Working in an integrated manner does not mean a clinician must hold more information necessarily. The clinician should be aware of avenues to go to seek out further information when the need arises.
One aspect of managing complex cases involves the challenges of those consumers who present with chronic risk factors. Most commonly this is seen in cases of ongoing and chronic suicidality and self-harm.