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FOLLOW-UP AND CASE MANAGEMENT

Throughout the follow-up period, the case manager continues to assess the client's psychosocial needs. This will include needs for housing and finance, interests, hobbies as well as peer group support and status of drug and alcohol use. For assistance with most of these needs a client is encouraged and, if needed, assisted to utilize generic community services. Although a major portion of the case management is dialogue-based, First Episode clients still require instrumental help in receiving the above community services.  

PEER GROUP

The young client's peer group is of particular significance. Knowledge about the client's peer group is essential in understanding who the client identifies with, what his/her interests might be, and how s/he spends time, etc. Of course, many clients can become isolated from their peer group due to the development of psychosis. In this case, the case manager will help the client re-establish a peer group. Initially, this can be accomplished by encouraging the client to attend the Recovery, Activity and Participation (RAP) Group or the Youth Education and Support Group (YES). Friendships are often forged during these groups. In some cases, the influence of the peer group can present obstacles to recovery for the client, eg., substance use/abuse. This points to the importance of the therapeutic alliance between the case manager and client. The power of persuasion on the part of the case manager often helps the client understand the dangers of using substances in the context of their vulnerability to relapse of psychotic episodes. The client must feel sufficient trust and acceptance to confide personal information about drug and alcohol use. A critical and punitive attitude on the part of the case manager is very likely to push the client away. The case manager creates an environment of acceptance and at the same time educate the client about the dangers of drugs and alcohol. The Youth Education and Support Group (YES) will supplement the one-to-one education given by case managers. Clients often discuss drug and alcohol use when in the company of their own peers. In the group intervention, they have the opportunity to role play situations as a means of acquiring skills to say 'No'. 

SUBSTANCE USE AND CASE MANAGEMENT

There may also be situations when the family is not aware of alcohol and/or drug use. The case manager may find him/herself in the awkward position of not being able to explain to families persistence of psychotic symptoms apparently unresponsive to treatment, when, in fact, substance abuse is a major contributor to the prevailing poor response. In this instance, case managers need to skillfully create and facilitate environments where the client can confide this information to his/her family. The case manager remains mindful of the confidential nature of the personal disclosure and is careful not to breach the trust that has developed. Referrals to Drug and Alcohol Programs are generally avoided except for liaison and assistance with assessment when necessary. It is always preferable that interventions directed at reducing or eliminating substance use/abuse are provided within the context of their primary therapeutic environment (program). 

RECOVERY AND TERMINATION

Each client is prepared for discharge from PEPP through each stage of treatment and recovery. Discharge is presented as a long-term goal and viewed as an accomplishment. Progress is to be reviewed at 3, 6 and 12 months on all goals identified at the initial assessment by the client, the family and the case manager. The 12 month review is more comprehensive in order to assist in reducing the intensity of case management. During the second year the patient is prepared for graduation to 'medical management only' with one of the program psychiatrists or a shared care between the psychiatrist and the family physician is accomplished at the end of two years. However, if at the end of the two years the client has made little progress clinically, a multi-disciplinary review identifies need for an additional year of intensive case management and propose changes in medical and psychosocial treatment strategies. The decision for the nature of follow-up beyond the first two years is made by the interdisciplinary team in consultation with the client and family. A formal meeting is held where all the information pertinent to the client's illness and functioning over two years is presented and discussed. 

Approximately 10-15% clients are likely to require intensive case management services beyond the two year period. A smaller proportion of clients may require long-term intensive case management and arrangements are to be made with existent mental health services. Termination from PEPP occurs within the guidelines of PEPP case management providing care for the first two years (in rare circumstances, three years). All patients are offered longer term follow up with their psychiatrist in the program with direct involvement of their family physician in a shared-care model.