[Long-term analysis of clinical disease activity and chronic organ damage in patients with systemic lupus erythematosus]. / Krankheitsaktivität und chronische Organschäden bei Patienten mit systemischem Lupus erythematosus (SLE) im Langzeitverlauf.

BACKGROUND: Systemic lupus erythematosus is a chronic inflammatory and systemic disease with multiple symptoms which is often characterized by a course of exacerbations. Over the last few decades the prognosis of SLE considerably improved with >90% patients living more than 10 years with their disease. AIM OF THE STUDY AND METHODS: The aim of this retrospective-descriptive analysis of 65 patients with the diagnosis of SLE (based on the ARA criteria) was to investigate the symptoms and the laboratory values at the time of diagnosis (TD) and over a period of 10 years (10Y) in the outpatient university clinic of the Department of Nephrology and Rheumatology at Goettingen. In addition to symptoms and laboratory values, disease activity, exacerbations, chronic organ failure, and medical therapy were to be investigated. RESULTS: The long-term analysis revealed a decline in the prevalence of ANAs (TD: 95.6%; >10Y: 78.6%), ds-DNA antibodies (TD: 78.0%; >10Y: 46.7%) and pathological levels of the complement component C3 (TD: 72.7%; >10Y: 42.9%) over time. The symptoms most prevalent at the time of first diagnosis such as the typical butterfly rash (TD: 50.0,%; >10Y: 36.8%), discoid skin lesions (TD: 38.8%; >10Y: 23.5%) were noted less often after a 10 year-disease course. On the contrary the frequency of arthralgias (TD: 61.2%; >10Y: 57.9%), myalgias (TD: 26.1%; >10Y: 26.3%) and fatigue (TD: 63.0%; >10Y: 64.7%) remained stable over time. The prevalence of arterial hypertension (TD: 17.2%; >10Y: 54.5%), proteinuria (TD: 33.3%; >10Y: 66.7%) and erythrocyturia (TD: 27.8%; >10Y: 44.4%) remarkably increased during the disease course. Besides renal damage, coronary artery disease (TD: 6.0%; >10Y: 23.0%) and neurological disease (e.g., cerebrovascular insults) (TD: 10.9%; >10Y: 26.3%) were noted more often after 10 years. Of patients, 56.9% developed one or several exacerbations of the disease. In all cases, clinical symptoms correlated with an increase in the level of ds-DNA-antibodies and a decrease of C3-complement component. Other medications included immunosuppressants, antihypertensive drugs and NSAIDs. High-dose steroids were preferred as the first diagnosis (TD: 44.4%; >10Y: 11.1%), while low-dose steroids were more often prescribed after a 10-years diseases course (TD: 6.7%; >10Y: 27.8%). CONCLUSIONS: There is a shift towards secondary organ damage with a decline of the inflammatory activity in patients with SLE after 10 years of disease. These consecutive diseases are due to the primary damage of SLE as well as to medical treatment (e.g., with steroids).

Hiring consumer-providers: barriers and alternative solutions.

The hiring of consumers as providers of mental health services has steadily increased over the last decade. This article, based on the literature and two round table discussions, explores three prevalent barriers (i.e., dual relationships, role conflict, and confidentiality) and proposes alternative solutions to each.

The experts speak: the critical ingredients of strengths model case management.

This study assessed the level of agreement among expert's opinion of the critical ingredients of the strengths model of case management. Twenty-eight experts rated the "significance" to the model of 72 elements/behaviors thought to be important and 8 distracter elements. There were also five open-ended questions asking for opinions on agency structure, service delivery, etc. The results found an extremely high agreement among the experts on virtually all items.

Implementing supported employment as an evidence-based practice.

Supported employment for people with severe mental illness is an evidence-based practice, based on converging findings from eight randomized controlled trials and three quasi-experimental studies. The critical ingredients of supported employment have been well described, and a fidelity scale differentiates supported employment programs from other types of vocational services. The effectiveness of supported employment appears to be generalizable across a broad range of client characteristics and community settings. More research is needed on long-term outcomes and on cost-effectiveness. Access to supported employment programs remains a problem, despite their increasing use throughout the United States. The authors discuss barriers to implementation and strategies for overcoming them based on successful experiences in several states.

Improving child welfare performance through supervisory use of client outcome data.

Despite their benefits, there is little evidence that outcome data are being widely used by program managers or field level supervisors. Three interdependent factors that facilitate the use of outcome data are well-constructed reports, and organizational culture that supports learning and outcome achievement, and managerial skills in interpreting data and taking relevant action. This article describes an outcome reporting package and training oriented toward frontline supervisors to help them use outcome data, shape a learning culture, interpret data, and take focused action toward improving outcomes for children and families.

The active ingredients of effective case management: a research synthesis.

As we move to managed care, the nature and role of case management is in flux and undetermined. Based on the outcome research, this paper seeks to identify the common elements of effective case management practice to guide its development under the new financing schema.

The first 18 months of mental health reform in Kansas.

OBJECTIVE: The effects of the first 18 months of implementation of the Kansas Mental Health Reform Act were evaluated. The act designated community mental health centers as gatekeepers for admission to mental health services, created screening and diversion services for state hospital admission, allocated state hospital bed days to each center, and reallocated funds from hospitals to communities. METHODS: Data from the catchment area in which reform was implemented in the 18-month study period, January 1991 to June 1992, were compared with data for that area before reform, and with data for the two state hospital catchment areas in which reform was not yet implemented. RESULTS: In the catchment area in which reform was implemented, state hospitalization decreased by about 29 percent, and state mental health funds allocated to the area's mental health centers almost doubled. Service utilization by patients discharged from the state hospital was higher than in the other two catchment areas, and most indicators of living status and vocational or educational involvement reflected improvement. CONCLUSIONS: The first 18 months of implementation suggest that state-level systems change can decrease state hospitalization and improve the utilization of community services while improving the quality of life for people with severe and persistent mental illness.

Research strategies for consumer empowerment of people with severe mental illness.

Research concerning the care and treatment of people with severe mental illness has not been consonant with the well-established emphasis on consumer empowerment in social work and the psychiatric rehabilitation field. This article provides a set of research strategies that would help bridge the gap. We argue that research should amplify "the voice of the consumer" by attending to the context of research, the vantage point, the process of formulating research questions, the selection of interventions to be tested, the selection of outcomes and measures, and the dissemination of research results.

Management is performance: strategies for client-centered practice in social service organizations.

The political nature of human services is a given. The multiple constituency dilemma coupled with the retrenchment of the 1970s and 1980s has led to a great gulf separating managers from clients, and managers from front-line personnel. These political factors have been reinforced by management theory and the blind adoption of "state-of-the-art" management technologies developed in business and the military, and the separation has gained legitimacy. The result is less than optimal service, a dissatisfied workforce, and continued attacks for being inefficient, self-serving, and ineffective. The purpose of this article is to portray an alternative form of human service management. Its vision places clients center stage in our organizations and places the manager as the director and producer. It accepts the premises that "management is the principle engine of progress" (Levitt, 1976) and that management is performance. It then lays a foundation for client-centered management by presenting four principles for social service administrators who desire to adopt this perspective in their daily practice. An elaboration of the skills and methods of client-centered management can be found in a recently published text (Rapp & Poertner, 1991).

Families' perceptions of community mental health programs for their relatives with a severe mental illness.

Realization that families are providing a major portion of the care for people with a severe and persistent mental illness has led to attempts to form an alliance with such families. Many professionals are aware that there is much cognitive distance between families and the professional community. Bridging this gap requires knowledge of the subjective experience of families. This paper reports the results of a study of the families' perspective of their experience with community mental health programs. Attention is given to the families' experience and needs; to changes in practice which address those needs; and to a variety of curriculum strategies for more adequately preparing future cadres of mental health professionals.

Factors related to successful goal attainment in case management.

Goal planning is fundamental to the case management process. Manager and client identify specific long-term goals and then systematically break them down into the incremental behaviors needed to be accomplished to achieve each goal. The goal-setting process may fail as a result of four types of factors: (1) behavioral, (2) cognitive, (3) affective, and (4) environmental. To decrease the likelihood of failure, case managers must be knowledgeable about goal planning. They must help the client set goals that are expressed positively, that are client focused, realistic and achievable, measurable, and easily understood, with one observable outcome per goal. For both case manager and client, setting and attaining goals must be viewed as part of a continuing learning process, rather than a success-failure dichotomy.

Improving client outcomes: the Kansas technical assistance consultation project.

A central problem in the design and implementation of mental health services is how to transfer relevant information to the active practitioner. Traditional methods of knowledge transfer, such as professional journals and workshops, appear to have uneven results at best. Outreach consultation services, here described as technical assistance, holds promise as an effective and efficient vehicle for transferring relevant knowledge necessary to improve professional practice. This report describes the technical assistance consultation project jointly sponsored by the University of Kansas, School of Social Welfare and the Kansas State Department of Mental Health and Retardation. It is argued that an important function of this project was symbolic as well as substantive. State departments of mental health and major public universities can work in consort to assist professionals and programs perform at a maximum level. Such an effort re-casts the manner in which these institutions are traditionally viewed by those engaged in direct practice. A case example is provided.

A decade of case management: a methodological review of outcome research.

The last decade has witnessed a burgeoning interest in case management services to people with severe mental illness. While the literature on case management is proliferating, there remains a paucity of rigorously designed outcome research. This paper provides a methodological review of that outcome research on case management, which found that the term case management is used to describe a diverse array of interventions that yield differing client outcomes. Suggestions for the direction of future inquiry are described.

Client outcome reporting: the status method.

This paper describes the development and results of a method for capturing client outcomes of community services for persons with severe mental illness. Through the use of status scales, two major elements of community integration, independence of living arrangement and vocational independence can be continuously monitored. The initial results of the method include: unifying previously disparate agendas of state and local officials, enhanced vocational and living arrangement outcomes for clients, instigating program improvements, and the increased exchange of staff rewards. In addition, the method is economical whereby data on a worker caseload of 30-40 can be collected in about 20 minutes.

Towards a model social work curriculum for practice with the chronically mentally ill.

Social work is well-positioned to mount a major curriculum initiative focused on practice with the chronically mentally ill. The profession's historical legacy, conceptual compatibility with current service needs, and its significant contribution to practice and research are a firm base upon which to build. This paper suggests the content needed to adequately prepare future cadres of professionals and proposes a variety of curriculum strategies for organizing such content. In addition, attention is devoted to the preparation of management personnel.

The evaluation of case management services with the chronically mentally ill.

This study reports the results of an experiment comparing a developmental-acquisition model of case management to usual case management services provided through a mental health center. This is the first study of case management with the chronically mentally ill to employ a true experimental design comparing two types of case management service. The statistically significant discriminant functions resulting from the analysis correctly classified 77% of the subjects based on the case manager's assessment of clients' socialization skills, assessment of community living skills by a significant other and the client, the client's tolerance of stress, use of leisure time, community behavior, and vocational training. Implications for research and service delivery are discussed.

Case management services for the chronically mentally ill.

Case management services have enjoyed a rapid increase in prominence within the mental health system as a solution to a variety of social service problems. The authors discuss a successful demonstration project that used social work students as case managers for the chronically mentally ill. An exploratory design was used and the results were positive for clients, students, and the system.

Information, performance, and the human service manager of the 1980s: beyond "housekeeping".

The use of information to guide management action and improve program performance is vastly different from current applications in the human services and will be one of the hallmarks of the second era of information system development. This paper, based on the literature and a recent statewide study, portrays first era information use as quite limited. A model for assessing and guiding future development is presented, which includes attention to organizational contingencies, arrangement of data-based reports, and manager skills and attitudes. A series of techniques for transforming data into management action is proposed.