Case management for the mentally ill: a comparative evaluation of client satisfaction

Health and Social Care in the Community 5(2), 106-1 15

Case management for the mentally ill: a comparative evaluation of client sat isfact ion

Deborah Cullen’ BA(Hons), Allyson Waite’ BSc(Hons), Nicolas Oliver’ MA, Jerome Carson’ BA(Hons), MSc, CPsychol and Frank Holloway2 MA, MRCPsych ‘Psychology Department, Institute of Psychiatry and ‘Maudsley Hospital, Denmark Hill, London, UK

Correspondence Frank Holloway Maudsley Hospital Denmark Hill London SE5 8AZ UK

Abstract This paper reports on client satisfaction with community mental health services. A Client Satisfaction Interview was used as one outcome measure in a randomized controlled study of clinical case management vs. standard community care. The Interview had high internal consistency reliability (Cronbachs alpha = 0.89) with very high inter-rater reliability for overall scores (Y = 0.99) and good inter-rater reliability for individual items (kappa over 0.9 for 18 of 22 items). Case management clients had significantly higher total satisfaction scores than control group clients who received standard community care at 9 months ( t = 2.02 P = 0.05) but not at baseline ( t = 0.59, P = 0.55) or 18 months ( t = 1.76, P = 0.09). In addition to a quantitative measure of satisfaction, clients were asked to provide more qualitative accounts of their experience with services. The findings are discussed in relation to the team’s model of case management and the differences between case management and control services. The limitations of this study are considered in the context of methodological issues surrounding measurement of client satisfaction and the study’s own methodological shortcomings.

Keywords: case management, mental illness, satisfaction

Accepted for publication 5 March 1996

Introduction

Satisfaction with services has been widely acknowl- edged to influence patient behaviours in terms of care seeking, compliance with treatment and maintaining contact with practitioners (Locker & Dunt 1978). However, it is only relatively recently that consumer views have been taken into account in the evaluation of mental health services in Britain. This has occurred in part as a response to Government initiatives that have emphasized the consumer perspective in the evaluation and monitoring of health services (Williams & Wilkinson 1995). However, the process of measuring consumer satisfaction has been fraught with numerous methodological difficulties (Webb 1993, Ruggeri 1994).

Studies of patient satisfaction with medical care tend to report high levels of satisfaction. Studies of

satisfaction with psychiatric services show similar results (e.g. Raphael 1972, Polowczyk et al. 1993). Where hospital-based care has been compared with community services greater satisfaction with community services has been found (Bene-Kociemba et al . 1982, Hoult et al. 1983). There is a tendency in evaluating client satisfaction to use global measures of satisfaction, although these often show little differences across settings and client groups (Essex 1981). A more fruitful approach is to examine satisfaction and dissatisfaction with specific aspects of the service being assessed (Holloway 1993). In addition qualitative data involving the comments of service users can usefully complement quantitative satisfaction data (Wykes & Carroll 1993).

Recently case management has been advocated as a solution for the perceived failings of community care for people with long-term mentally illness. The broad

106 0 1997 Blackwell Science Ltd

Case management: satisfaction with care

aims of case management are to ’enhance the continu- ity of care and its accessibility, accountability and efficiency’ (Intagliata 1982). Outcome studies of case management, including a satisfaction measure, report a trend towards improved satisfaction with services (Wasylenki et al. 1985, Goering et al. 1988, Wright et al. 1989, Muijen et al. 1992) compared with traditional services. In addition, case managed clients have been reported to receive more services, to have fewer unmet service needs (Bigelow 1991) and to be more likely to still stay in contact with services 6 months after dis- charge from hospital (Wright et al. 1989).

There have been few controlled studies of case management in Britain (Holloway et al. 1995). This paper reports on the findings of a randomized controlled trial of an intensive case management service vs. standard care for patients with severe mental illness. An integral outcome measure was client satisfaction with services and the results are presented along with qualitative comments from service users. In the light of existing research, it was hypothesized that case management clients would report greater levels of satisfaction with services.

Methods

Participants were clients involved in the evaluation of an intensive clinical case management service compared with standard control services in a London inner-city area. All clients in the study were aged between 16 and 65 years and lived in a defined inner urban catchment area. All clients had a diagnosis of functional psychosis and had evidence of previous unsatisfactory engagement with mental health services, manifested by previous non-compliance with treatment, frequent readmission or poor symptomatic response to conventional management. Admission to the project was by referral from psychiatrists and other members of the multidisciplinary team. After baseline assessment clients were allocated randomly to the case management or control groups. Clients were inter- viewed at baseline (before randomization) and then 9 and 18 months later. The design was of an ’intention to treat’ type and attempts were made to follow up all 70 patients who gave consent to be entered into the study. Randomization was by sealed envelope utilizing ran- dom permuted blocks.

The case management service was delivered by a multidisciplinary team (four psychiatric nurses, one occupational therapist, with sessional input from a clinical psychologist and psychiatrist). The team worked to the model of clinical case management delineated by Kanter (1989). There were four aspects to the team’s functioning: engagement and assessment,

direct ’clinical’ work, ’social care’, and brokerage or advocacy. Interventions included: the assessment of mental state, the provision and monitoring of medication, intervention in crisis, psycho-education and fam- ily therapy and assistance with practical aspects of daily living (including welfare benefits). The team sought to be accessible to clients with an ’open door’ policy at their base, in addition offering a regular socially orientated drop-in service. The case managers advocated on behalf of their clients with other health and social welfare agencies. Project clients’ care plans were reviewed regularly in a multidisciplinary meet- ing. The day-to-day running of the service is described in more detail elsewhere (Holloway ef al. in press).

The control group received the standard services available in the catchment area including input from community psychiatric nurses, social workers and a depot anti-psychotic clinic. Staff working with clients in both the case management and the control group referred to other services as appropriate, subject to the normal local service provision constraints.

This paper presents the findings from the investiga- tion of clients’ satisfaction with the services received during the course of the study. The measure used was developed by the research team but strongly influ- enced by other published measures (e.g. the General Satisfaction Questionnaire, Huxley & Mohamad 1991-2). The questionnaire had 22 satisfaction items each rated on a 4-point scale (0 = dissatisfied to 3 = very satisfied). During the course of the interview clients were also asked what they considered to be the positive and negative aspects of the service and how this could be improved; verbatim comments are used to complement quantitative data.

Results

Client characteristics

Socio-demographic characteristics of all the clients involved in the study are presented in Table 1. Project clients were typically male, in their 30s and had been suffering from a schizophrenic illness for over a decade. The majority were from ethnic minorities (largely Afro-Caribbean).

Reliability of the satisfaction interview

Twenty-one pairs of satisfaction interviews were carried out by members of the research team who had had previous training. The correlation between overall satisfaction scores (calculated by summing across all items) was high (Y = 0.99). For individual items reliability was very high (kappa > 0.9 for 18 of 22 items). Cronbach’s alpha for the scale was 0.89.

0 1997 Blackwell Science Ltd, Health and Social Care in the Community 5(2), 106-1 15 107

D. Cullen eta/.

Table 1 Socio-demographic characteristics of control and case management groups at baseline interviews

Case management Control n = 35 n=35

Number % Number %

Sex Male Female

Age group (years) < 20 20-29 30-39 40-49 50-59 60 +

22 63 24 69 13 37 11 31

0 0 1 3 9 26 14 40

17 49 11 31 5 14 6 17 2 5 2 5 2 6 1 3

Hospital diagnosis Schizophrenia and related disorders 29 83 35 100

Bipolar affective disorder 6 17 0 0

Ethnic origin White Non-white

Years since

17 49 15 43 18 51 20 57

onset of illness Mean (standard deviation) 12.7 (8.3) 10.5 (8.9)

Fifty-seven per cent of control and 68% of case management clients agreed to a full satisfaction interview at 9 months and 51 % of control and 60% of case management clients agreed to a full satisfaction interview at an 18-month follow-up

failed to reach significance (MANOVA F= 2.8, P = 0.076). For the two groups combined satisfaction improved significantly over time (MANOVA F = 16.9, P < 0.001).

Individual satisfaction items

Overall satisfaction

The mean total satisfaction scores at baseline, 9-month and 18-month follow-up are shown in Table 2. There was no significant difference between groups at baseline (t = 0.59, P = 0.55) or at 18 months (t = 1.76, P = 0.09), but the difference at 9 months was significant (t = 2.02, P = 0.05). A multivariate analysis of variance of the effect of project status on satisfaction scores at 9 and 18 months with baseline scores as a co-variate

For the purposes of presentation individual items of the satisfaction interview were grouped a priori into five categories: general satisfaction (five items), appointments (five items), service provider qualities (five items), provision of information (three items), and specific aspects of treatment and care (four items). The items comprising these categories are presented in Appendix 1.

Responses on each item were recoded into ’satisfied’ (scores of 3 and 2) and ‘dissatisfied‘ (scores of 1 and 0).

Table 2 Total satisfaction scores for case

months and 18 months Baseline 9 months 18 months management control patients at baseline, 9

Case management n = 2 8 II = 26 n = 22 mean (standard deviation) 39.2 (18.1) 55.4 (9.1) 56.0 (9.7)

Control n = 31 n = 21 n = 1 8 mean (standard deviation) 41.8 (5.4) 49.0 (12.6) 48.3 (17.6) significance test t = 0.59, P = 0.55 t = 2.02, P = 0.05 t = 1.76, P = 0.09

108 0 1997 Blackwell Science Ltd, Health and Social Care in the Community 5(2), 106-1 15


The data were analysed using the chi-square statistic or Fisher’s exact test as appropriate in two-by-two contingency tables (control/case management vs. dissatisfied/satisfied). The frequencies for the contingency tables at baseline, 9 months and 18 months are presented in Tables 3,4,5,6 and 7. There were no sigruficant differences in levels of satisfaction found at baseline between those clients who were later to drop out of the interview process and those who completed it. Given the numbers of significance tests carried out, the results which follow should be considered as mainly suggestive.

General satisfaction

Case management clients were significantly more satisfied at 9 months than control patients on three of the five general items (see Table 3). There were no significant differences between the two groups at baseline and at 18-month follow-up, mainly due to an increase in satisfaction by control patients between nine and 18 months.

Case management clients spoke of being particularly satisfied with the range of help that was offered. This covered a broad spectrum of tasks and activities:

Any problem, she’ll sort it out -welfare, letters, medication’ ‘I never encountered help like this before - money, financial difficulties, hobbies, activities, making sure that I’m keeping myself organized - it’s been different.

There were also many comments highlighting the difference between the case management service and previous help clients had received:

Before, people just told me to keep taking the medication, but now people talk to me.

The help now is much better than before - people are concerned that my day is structured properly.

My case manager used to come to the flat, make cups of tea and chat with me - it was very helpful. No one from the hospital has ever done that before.

Appointments

There were no differences between case management and control patients in items relating to appointments (see Table 4) at any time point, and generally satisfaction was high. Many clients spoke of the importance of seeing someone regularly. The following comments, the first from a case management client and the second from a control group client illustrates the importance of regular help and support and the potential consequences of being without it:

When something happens, it might start building over the course of a few weeks. Before, I might start drinking heavily and end up in hospital. Seeing someone every week puts things into perspective.

When I get ill, I get no help at all. I can’t manage myself. I was going insane in my bedroom for four months ... social worker was contacted and didn’t come .... she doesn’t give me enough help.

There was, however, considerable individual variation as to the ideal frequency of visits by workers. Some individuals cited almost daily contact as optimum, whereas others felt they were seen ‘more than enough’ and would have been satisfied with contact once a month. Clients also showed some understanding of the difficulties and demands facing their workers. One client remarked that giving enough help to those who needed it was like ‘feeding the five thousand’, a seem- ingly impossible task. Many clients echoed the feelings of one who commented that:

. . . it would be better if there was more time, more nurses.

Baseline 9 months 18 months

(n = 28) ( n = 31) ( n = 26) (n = 21) ( n = 22) ( n = 18) CM(%) CTR(%) CM(%) CTR(%) CM(%) CTR(%)

Service quality 68 59 100 65 73 65% x2 = 7.9, P = 0.005

Needs met 53 54 88 53 90 71 % x2 = 6.8, P = 0.009

Overall satisfaction 74 68 96 71 100 82% Fisher P = 0.035

Type of service 78 70 96 75 95 76%

Help you get 72 69 88 81 91 67%

Table 3 Percentage of respondents reporting satisfaction at baseline, 9 month and 18 month follow-up for case management (CM) and control (CTR) clients: (overall satisfaction items)


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Table 4 Percentage of respondents reporting satisfaction at baseline, 9 month

management (CM) and control (CTR) clients: (appointments items)


( n = 28) (n = 31) (n = 26) (n 21) ( n = 22) (n = 18) CM (%) CTR (%) CM (%) CTR (96) CM (%) CTR (%) and 18 month follow-up for

Place of

Time of

Frequency of

Warning of

Timing of

appointment 83 86 84 95 95 82

appointment 78 90 96 95 91 87

appointment 67 67 89 80 86 89

appointment 80 81 96 95 100 88

appointment 82 68 2 94 75 72

Service provider qualities

Respondents were generally positive about their professional carers (see Table 5). At 18 months the case management clients were significantly more satisfied than controls about the understanding shown by staff of their problems but there were otherwise no significant differences between the two groups.

Many case management clients reported the importance of having someone they liked and trusted around:

They‘re there to talk to, if you want a chat, any worries you can just have a chat and they put your mind at rest.

. . . [my case manager] kept me alive - if I didn’t meet her I think I’d be a lot worse.

. . . [my case manager] is everything rolled into one: counsel- lor, nurse, someone to talk to, a shoulder to cry on - she’s like my ’spiritual sister’.

The more I get to know her, the more I can talk to her and tell her things.

They understand me now, it took a bit of time.

A common complaint in both the control and case

management group was the lack of contact with their psychiatrist, which occurred, on average, once every 4 or 6 weeks. This may have contributed to the difficulties communicating with and the alienation from some doctors that some clients reported:

There’s a barrier between me and the doctors; they don’t really want to talk to me but X [case manager] does.

. . . [my case manager] really wants to help me; she’s on my side whereas the doctors are against me.

... [my case manager] doesn’t agree that John the Baptist spoke to me, but she has an open mind. The doctors just think I’m mad.

Clients also reported dissatisfaction with the tempo- rary nature of doctors’ placements, a consequence of the rotation of junior medical staff:

X [the doctor] listens and accepts, but she is only there for six months and then she’s gone. It’s frustrating and annoying.

I see X [my consultant] once in a blue moon; that’s OK as long as the junior doctor listens to me. She [the junior doctor] is nice, I’d like her to be permanent. They should have someone there [at the day hospital] permanently, like a GP, not in tran- sit all the time.

Table 5 Percentage of respondents Baseline 9 months 18 months reporting satisfaction at baseline, 9 month CM (%) CTR (%) CM (%I CTR (%) CM (%) CTR (%) and 18 month follow-up for case (n = 28) ( n = 31) (n = 21) (n = 26) ( n = 22) ( n = 18) management (CM) and control (CTR)

clients (service provider items) Staff attitudes 71 81 96 91 91 89

Staff understanding 61 74 89 81 95 65 Fisher P = 0.02

Staff competence 78 83 100 85 95 78 Staff confidentiality 85 89 91 95 95 93 Keyworker 87 80 100 94 96 100



The provision of information

At baseline patients were notably dissatisfied with the information that they received from staff. Satisfaction with these items improved markedly by the nine month follow-up for both case-managed and control patients (see Table 6). The case management group were significantly more satisfied than controls at 18 months on one of the three items (staff understanding of the client’s problems). Respondents noted the difficulties they experienced in communicating with staff, not just their doctors:

It’s like a glass between the staff and me.

The style of the communication was also identified as important:

It’s not all rigid and formal -you can talk about anything.

She gives me answers that I can understand ... we seem to understand each other.

However, the mere provision of information and advice may not be perceived as adequate to meet clients’ needs:

They give me advice but nothing seems to be done.

Specific aspects of treatment and care

Case managed clients were significantly more satisfied with the help they received with their social problems at 9 months but not at 18 months: this was due to an increase in satisfaction by control patients between 9 and 18 months (see Table 7). There were no differences between the two groups regarding attitudes to medication (an area where it had been predicted that case management would have an impact) and little evidence of change over time for this item. Satisfaction with the ease of contact with services became significantly worse for case managed clients at 18 months.

Although clients in both groups noted an improve- ment in the response of services to requests for help in an emergency over time, they remarked on the diffi-

culty of obtaining help ’out of hours’. Whereas some clients were not actively dissatisfied with this situation others expressed dissatisfaction that their only option would be to contact the local emergency psychiatric clinic and be treated by people unfamiliar with them and their circumstances. Some clients did not turn to services at all at these times:

Outside of 9-5 I rely on my friends.

At weekends I’d turn to my parents.

Within service hours clients held widely differing opinions on ease of access, ranging from ’impossible’ to ’easy on weekdays’. Most mentioned the possibility of telephoning workers in their offices if they needed help, but many talked about the frustrations of engaged lines or having to leave messages on answer- phones. The comments of the case management clients suggested they were gratified by the option of being able to come in and see somebody directly:

If phoning, the lines are engaged; if I come in myself I‘ve been seen straight away.

I usually come in [if I need help]. If X [case manager] isn’t here there’s always someone else.

This direct access diminished during the life of the research project (Holloway et aZ. in press). Clients’ comments indicated that they valued the practical help that was avaiIable from the case management service very highly:

I haven’t any problems with bills now X [case manager] helps me with them if I have any queries, she sorts something out.

I’m mostly satisfied with the treatment; there’s been lots of practical help, they’ve helped me get grants.

I enjoy chatting with X [case manager] and getting help with shopping and cooking.

They give me help with buying things for the flat and help at home like clearing away rubbish.

X [case manager] helped me with personal problems, poll tax, the council . . . without her help I’d have been lost.

Table 6 Percentage of respondents Baseline 9 months 18 months reporting satisfaction at baseline, 9 month CM (%) CTR (%) CM (%) CTR (%) CM (%) CTR (%) and 18 month follow-up for case (n = 28) (n = 31) (n = 21) (?7 = 26) (n = 22) ( n = 18) management (CM) and control (CTR)

clients: (information items) Informa tion

from staff 64 59 84 81 100 76 Fisher P = 0.02

Staff answers

Advice re to questions 62 59 84 95 86 82

other services 46 56 88 71 76 71


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Table 7 Percentage of respondents reporting satisfaction at baseline, 9 month

management (CM) and control (CTR) clients: (Specific items)


(n = 28) (n = 31) (n = 26) (n = 21) (n = 22) (n = 18) CM (%) CTR (%) CM (%) CTR (%) CM (%) CTR (%) and 18 month follow-up for

Emergency response 58 62 91 71 87 87

East of contact 74 74 79 68 48 88

Help with x2 = 5.02 P = 0.02

social problem 52 65 96 70 86 86

Medication 64 57 54 58 71 73 Fisher P = 0.034

They also reported dissatisfaction when this help was not available:

I’d like someone to help me with the cleaning, somebody helping me would give me the incentive.

When they come and visit me they ask if I’m OK, have a chat and leave. I want extra money to get beds for the children - practical help.

One aspect of the case management service that clients appeared particularly satisfied with and identified as helpful was support and assistance in going out:

X [case manager] takes me out for a coffee sometimes, we’re planning to go to the pictures.

If it’s nice weather she’ll suggest we meet somewhere, and she treats me to lunch.

She thought about me even when I was ill, she took me to Crystal Palace to the park.

I particularly liked it when they took me out for the day - to the Tate Gallery and the Crystal Palace.

The importance of advocacy one of the core case management functions was identified by service users:

I talked to X [case manager] about my problems, she arranged an earlier appointment with the doctor to change my tablets to different ones.

I wanted more cupboards but X [worker] isn’t helping me approach the council who haven’t carried out the repairs they’ve promised.

Discussion

Case managed clients had significantly higher overall satisfaction scores than controls at 9 months follow-up with only a trend in favour of case management at 18 months.

The qualitative comments reported suggest that the difference between case management and standard

care perceived by service users was related to the range of activities undertaken by the case management team and the contrasting style of working compared with previous traditional services. These results and comments are encouraging in that they reflect the successful implementation of the model of clinical case management adopted by the case management service (Kanter 1989). This model of service delivery stresses that clinical case management should be ’concerned with all aspects of their patients’ physical and social environment, including housing, psychiatric treatment, health care, entitlements, families and social net- works’. The comprehensiveness of the case management approach appeared to be much appreciated by the clients.

One striking aspect of the case management team’s working was the ease of access that it offered clients. The team operated an open-door policy by which clients were encouraged to call in if they had a problem or just wanted somewhere to go and a drop-in service. The case management team was successful in engag- ing patients who had previously failed to engage with services, and its accessibility and flexibility may have been important in this success. However, at 18-month follow-up case management clients were significantly less satisfied with their ease of access to services than controls and showed a marked decrease in the percentage of clients satisfied. This finding may be explained in part by the reorganization of the local community mental health services into smaller teams, each serving a particular geographical sector, which may have facil- itated the control group community services to become more ’case management-like’ in terms of their accessibility. It also reflects a loss of service experienced by case management clients as the team became less accessible.

Another focus of the case management service was in improving clients’ social conditions, which was often tackled early on in the process of engagement. Specifically, clients received help with their welfare



benefits which often resulted in a significant increase in their income. That this was successful can be inferred from the marked increase observed in case managed respondent’s satisfaction with the help they received for their social problems at 9 months. At 18 months control patients had shown similar increases in satisfaction, possibly reflecting a change in the ori- entation of the reorganized local services towards a more holistic approach to community mental health care. It had been expected that intensive case management would improve patient understanding of and compliance with medication: case managers spent considerable time discussing medication issues with their clients. This activity was not reflected in any noticeable change in clients’ attitudes towards their medication.

Respondents in both groups were consistently positive about the staff who cared for them (except their psychiatrists) and the arrangements for appointments with staff. They were initially much less positive about the information and advice received from staff, although this improved over time in both groups. The clinical case management service was a time intensive service with clients being seen at least fortnightly and often more than once a week and at times daily. Choice of appointment or visit location was client determined as was frequency. For the control group, visits were much more likely to be fortnightly to monthly with little choice about location. However, these differences in provision were not reflected in differences in rated satisfaction.

As with other studies of satisfaction the present study suffers from methodological limitations common to the literature on satisfaction with care (Ruggieri 1994). Clearly these must be considered when interpreting the data and considered by future researchers of users’ views of psychiatric care.

The measure used in the current study was designed in-house, albeit partly modelled on existing scales, and was not piloted before use in the study. Initial experience with the scale suggests that it is reli- able and produces results that are interpretable. Researchers may wish to utilize an scale with well- established psychometric properties, e.g. the General Satisfaction Questionnaire (Huxley & Mohamad 1991-92) or the Verona Service Satisfaction Scale (Ruggeri & Dall’Agnola 1993), although this might mean a failure to investigate areas of satisfaction specific to a service.

Specific to this study, the sample size was relatively small and therefore there are problems in generalizing to other populations. However, the sample is likely to be representative of ’hard to treat’ patients with psychotic illnesses in contact with inner-city services.

Related to small sample size, there was a significant proportion of clients who refused to participate in the

interviews (17% at baseline; 33% at first follow-up and 44% at second follow-up). It is possible that the clients who did complete the interviews were not representative of the whole sample, although there were no significant differences between refusers and respondents on a range of baseline sociodemographic and clinical measures. In general, unsatisfied clients are more likely to drop out of studies of satisfaction (El-Guebaly ef al. 1983). There were more drop-outs from the control than the case managed condition at 9 and 18 months, which is consistent with the apparent increased satisfaction amongst the case management clients who did respond to the interview.

Assessors were not blind to the treatment condition. This raises the possibility of assessor bias (although the reliability of the interview was high). Attempts to blind assessors to treatment condition would have made it impossible to collect the qualitative data which we sought.

The method of analysis by which responses are dichotomized into satisfied vs. dissatisfied may obscure more subtle group differences. It could be that with a sensitive enough measure, differences in ’amount’ of satisfaction might be investigated rather than gross comparisons of satisfaction/dissatisfaction. In this study an overall satisfaction score was calculated to provide a measure of overall satisfaction: the overall scores differentiated between groups at 9 months but not at 18 months. It is argued that over the study period the control condition took on many of the characteristics of the case management service.

A major problem in this field of research is the lack of an agreed definition of satisfaction - ’the term satisfaction is defined differently by individuals as a result of varying backgrounds and experiences’ (Ware 1983). There are additional conceptual problems with the measurement of client satisfaction similar to those encountered in the measurement of sub- jective quality of life (Oliver et al . 1995). The cognitive processes involved in making a judgement of satisfaction are not transparent to the administrator of a satisfaction questionnaire. To compare ratings of satisfaction across individuals implies a universality of rating; that ‘mostly satisfied’ means the same for different people. Even to compare within individuals longitudinally has its problems. Stimson & Webb (1975) suggest that satisfaction is related to the extent to which services meet clients’ expectations. It is con- ceivable that such expectations change over time but this is not an issue that is addressed by current measures. In the current study case managed respondents initially reacted favourably to the accessibility of the service but became less satisfied as this extreme degree of availability was decreased.


D. Cullen eta/.

Studies report high levels of satisfaction, typically between 70 and 90% (Damkot et al. 1983). This may well be explained by the effects of social desirability in responding and acquiescence. High baseline levels of satisfaction make detection of change difficult due to a ceiling effect, apparent in this study in the very positive responses to questions about staff qualities and arrangements about appointments. It is notable however, in the current study that there were a number of individual items where 40% or more of the sample reported dissatisfaction at baseline: the extent to which respondents felt their needs were met, the help that they received for their social problems, their medication, responses to urgent requests for help, staff responses to questions, and the advice respondents received about other agencies. All these areas improved substantially over time except satisfaction with medication.

The collection of qualitative data highlights important service satisfaction dimensions often overlooked by existing measures. Consistent with this Elbeck & Fecteau (1990) advocate the use a more unstructured, qualitative approach to elicit clients’ feelings regarding the services they receive. Keeping in mind the limitations outlined above, the current paper presents insights into factors contributing to clients’ satisfaction with community mental health services. It suggests that services that are comprehensive, flexible and accessible will be valued and positively regarded by the clients who receive them.

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361-368.

589-91.

21 2-227.



Appendix 1

Client satisfaction interview

All items rated on a 4 point scale: 0 = dissatisfied 1 = mildly dissatisfied or indifferent 2 = mostly satisfied 3 = very satisfied

General service satisfaction 1. How would you rate the quality of service you receive? 2. To what extent has the service you receive met your needs? 3. In an overall, general sense, how satisfied are you with the

4. How satisfied are you with the kind of service you

5. How satisfied are you with the amount of help you

service you receive?

receive?

receive from the service?

Appointments: how satisfied are you with . . . 1. the places you have your appointments? 2. the times of your appointments? 3. how often you have an appointment? 4. how much warning the service gives you about your next

appointment? 5. how much notice people take if you ask for an appoint-

ment to be at a certain time of the day or on (or not on) a certain day?

Information and advice: how satisfied are you with . . . 1. the advice or contacts you are given about other agencies

that can help you? 2. the information given to you, by the members of the ser-

vice, about your problems, needs and the care you receive? 3. the way your questions are answered?

Service provider qualities: how satisfied are you with . . . 1. the attitudes of the members of the service when they see

2. the way the staff understand your needs, problems, diffi-

3. that the staff seem to know what they are doing? 4. with the degree of confidentiality shown by members of

the service? 5. our keyworker?

you? (How they treat you?)

culties?

Specific aspects of care: how satisfied are you with . . . 1. the time taken for the service to respond to a request for

2. how easy it is to get in touch with someone involved with

3. the help you receive for social problems/difficulties, e.g.

4. your medication?

help?

your care?

sorting out housing, benefits


Case management for the mentally ill: a comparative evaluation of client satisfaction

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