Social workers’ experiences of integrated case management for low-income individuals with mental illness in South Korea

Introduction

Case management is a major component of the current mainstream of social work practice; it is defined as a practice model composed of exhaustive, systematic and consistent community care activities to provide the best service for people with multiple needs (National Association of Social Workers [NASW], 2013). Integrated case management, however, is a more specific term that includes the role of case managers to integrate formal systems of care with the clients yet help them reach their full potential by facilitating more effective interaction across agencies as well as the larger social environment and continuously monitoring its processes (Korea Ministry of Health and Welfare, the Hope Forum, 2014). Essentially, integrated case management is a more aggressive form of practice model that primarily focuses on resource development, management and networking activities for the sake of the best interests of clients whose needs could not be met by a single agency. There is thus a fine line between integrated case management and simple cooperation or collaboration activities, as the latter is a method of co-working form, while the former includes the latter yet runs based on concrete planning and inter-exchange of coordinated services provided by a team of professionals (Choi, 2010; Tate and Hubberstey, 1997). Nonetheless, there still exist various issues pertaining to successful integrated case management, such as poor knowledge of integrated case management practice models, fragmentation of community resources, insufficient assessment of or difficulty in assessing clients’ primary needs, differences in what each agency pursues as their organisational framework for best practice, and lack of time and commitment of social workers (Kathol et al., 2010; Queensland Council of Social Services, 2013).

In South Korea, the absence of agreement among scholars and practitioners on the term integrated social work case management and a lack of nationally supported standards for case management have caused social work practice to become more confusing and discouraged professionals from performing at a higher level. As Suh et al. (2011) suggested, the country’s present social service delivery system is incompetent regarding the extent of networking and cooperation with other social service providers, not to mention a lack of resources that deters productive responses. Do (2011) pointed out some major issues that significantly hinder successful case management in South Korea, including the dearth and immobility of resources, which stems from agencies ‘not sharing’ with each other; communication gaps between agencies; as well as non-standardised forms of service provision, both at the agency level and nationwide. This is an especially serious issue for people with severe psychiatric disabilities because they are often limited to making independent use of various social services (e.g. education, housing and recreation) to meet their multiple needs (Anthony et al., 2000).

Lately there has been a change in how Korean practitioners view case management, similar to Anthony et al. (2000), who suggested that the client’s goals should drive case management and not the aims of the system. Specifically, in Jang et al. (2015) and according to the Cheongju Welfare Foundation (2014), social workers from the private and public sectors, as well as the health and social service systems, expressed similar levels of understanding regarding the concept of integrated case management. That is, they all understand integrated case management as an ‘integrated approach involving multiple professionals and/or agencies’. Participants unanimously agreed that ‘[the term] is absolutely necessary and essentially a resource map that can guide us toward a better practise’, ‘because a single agency cannot meet clients’ every need’ (p. 341). However, social workers in general practice expressed tremendous frustration at helping mentally challenged clients, due to insufficient mental health training and poor collaboration with mental health professionals. As such, given the similar level of understanding and willingness to work together across agencies, the concept of ‘partnership’ seems extremely important in delivering successful integrated case management.

The link between poverty and mental illness has been well documented in multiple studies; low-income families experiencing mental illness require special attention. In fact, a greater number of self-support targets in South Korea require professional help for their mental health issues, including substance abuse and various mental disabilities. Among these individuals, those with a lower household income are twice as likely to experience mental illness, especially depression (Danziger et al., 2000), and more prone to undergoing extreme difficulties in gaining financial independency. There are also non-mental health needs, including education, employment and financial assistance (that closely relate to low income; Kessler et al., 2005). Moreover, having a mental health problem is a major barrier that prevents beneficiaries of national basic livelihood (Korea’s social security system) from becoming independent (Jayakody et al., 2000; Lee et al., 2011). In turn, having non-mental health needs such as poor physical health (e.g. chronic diseases or pain management), education, employment, finances, housing, childcare, domestic violence, legal issues and rehabilitation due to substance use disorders (a very common co-morbid issue among individuals experiencing mental illness) exacerbates the situation for individuals experiencing mental illness (Eom, 2006).

Simply put, it is a tough challenge for an agency to meet the complex needs presented by low-income individuals experiencing mental illness, especially when these resources are fragmented throughout the community in South Korea. To overcome such incompetency, integrated case management is necessary that is based on inter-exchange of active coordinated services collaboratively provided by both private and public sectors responsible for a variety of services, including health, welfare, legal services, education, housing and so on. Unfortunately, South Korea’s contemporary mental health care system focuses primarily on treating mental disorders only through specialised services provided by trained and licensed professionals. Therefore, the ability or willingness of mental health professionals to offer mental health services to non-mental health agencies is an extremely important factor. In other words, the success of integrated case management in a mental health setting is presumably impacted by the degree of inter-agency networking and its influence on simultaneously helping professionals obtain resources other than those that relate to mental health. This will more effectively assist workers in dealing with multiple needs of individuals who are limited in their ability by mental illness and/or co-morbid substance use issue.

In essence, case management for individuals experiencing mental illness should involve various activities that the clients may be incapable of doing themselves or are only able to perform to a limited extent due to their illness; these pursuits include identifying adequate service recipients, planning for services, linking clients with services and advocating for service improvements (Anthony et al., 2000). Given the urgent need for strong partnerships across various agencies (Do, 2011; Jang et al., 2015; Kim, 2013), we aimed to learn about social workers’ experiences of integrated case management by examining barriers to successful cooperation and the current situation of networking across various agencies.

Methods

Results

Findings were summarised into these three overarching themes: (1) struggling with limited resources (both human and material) while unrealistic expectations are imposed on mental health professionals, which impedes efficient collaboration; (2) a lack of collaboration among agencies and limited networking activities; and (3) the need for a functional organisation that can play a central role in building a stronger system for effective integrated case management. Quotes that best represent each theme or one of its sub-themes are included in the following sections; respondent identification numbers are provided for each quote.

Quantitative findings

On examining the current state of networking among mental health services and other social service facilities, we observed a total of 9312 joint efforts among 397 social service agencies for 8671 cases within the 1-year study period (1 January 2013–31 December 2013). As anticipated, agencies rated service networking as the most sought-after purpose for cooperation among agencies (74.5%), which far outnumbered other objectives such as client referrals (14.4%), professionals sharing information with each other about managing individual cases (8.5%), external supervision for case management (<1%), case conferences (<1%), and education on case management (<1%).

This implies that C province relied heavily on inter-agency partnerships to conduct service outreach in a given year. Unfortunately, among these cases, less than 10% of networking activities (6.3% or 545 cases; 7.2% or 669 events in terms of collaboration frequency) related to helping individuals with physical or mental health needs, the vast majority of these activities being client referrals, rather than concerning cooperation.

In addition, social service agencies had the lowest rate of partnership with health and mental health agencies (achieving only 11.1% of collaboration activities); this indicates a consistent pattern with qualitative findings regarding a lack of teamwork in mental health settings. The most frequent cooperation occurred with other social service agencies (42.4%), similar to their kind of social service agencies, followed by social service administrative agencies (28.2%) and voluntary organisations or civic groups (18.5%). In essence, this reflected the minimum exchange of services with mental health agencies, which echoes the issue of liability and burden brought up by mental health professionals in the qualitative findings.

Interestingly, mental health professionals reported that they frequently worked with the private sector (38.9%) and the public sector (47.6%), indicating uneven levels of networking and supply and demand for mental health services, as confirmed by respondents. Social service and welfare administrative agencies most frequently requested service networking (55.7%) and client referrals (41.4%) from mental health professionals. This is consistent with how mental health professionals saw their role in teamwork as ‘taking over’ or becoming ‘in charge’ regarding contact with clients. The following sample quote notes the lack of continuity and responsibility in mental health cases:

It’s frustrating … agencies refer their clients to us, which often think they’ve done their part and that now we should solve everything. (MHC_R_C)

Results from SNA confirmed these patterns. As shown in Figure 1, the vast majority of the larger nodes (in squares) in service networking were agencies offering services other than mental health, including general social services for adolescents, the disabled and the elderly. In addition, the agencies offered to provide a community health centre, a medical centre and external donations (monetary or goods), including a department store. A local welfare centre for the physically disabled and a community health centre were among the most centralised (larger nodes) and overloaded agencies that worked together the most within C province.

OPEN IN VIEWER

Figure 1.

SNA results of the current state of service exchange.

Conclusion

This article discusses the current circumstances of integrated case management in South Korea, especially in terms of social workers’ experiences in assisting low-income individuals with complex needs, specifically mental health issues. Lately, the Korean government has required social service agencies to actively respond to the multiple needs of low-income people with mental illness (Korea Ministry of Health and Welfare, the Hope Forum, 2014) because these cases are some of the most difficult and urgent and necessitate comprehensive care for a variety of non-mental health issues including poverty, employment, finance, childcare, housing, health, domestic violence and alcoholism.

Major findings of this study revealed poor collaboration between mental health entities and other social service agencies, which resulted in mental health services being inconsistently and unreliably provided. The following text summarises the findings and discusses implications for social work practice.

First, we identified limited human and material resources in the community as a significant barrier to practising integrated case management. With growing mental health needs yet only a couple of mental health agencies available, and very few trained, licensed professionals within a given community, respondents unanimously expressed their frustration at not being able to provide appropriate, timely care. This was referred to as the ‘drying-up well’ phenomenon in Jang et al. (2015), where there was a heavy concentration of collaboration requests made by many facilities on very few agencies, indicating limited resources and high dependency issues. Particularly, the HW Welfare Center for the Disabled and the HD Community Health Center (second largest node) were among the most centralised and overloaded agencies in supporting various other agencies. While this is understandable given the great scarcity of resources available for the disabled compared to the enormous needs in the C province, the results reinforce the need to further conclude an agreement among agencies covering issues from resource development to sharing and dissemination, suggested in the following on strategies for improved partnership.

This finding echoes Ha et al.’s (2014) recent findings on social work case managers’ great concerns about poor quality of case management due to the issue of case overload, as well as clients’ experiences of helplessness and limited resources issues. As a matter of fact, case managers at local mental health centres are usually assigned, on average, 50 cases, with telephone follow-ups possible only once or twice in a given month (Hwang, 2008). This unreasonable caseload issue indicates the shortage of manpower in the system thus hindering performance.

This overload issue is of great concern, particularly in the case of Province C, a mid-size city in South Korea. This is because there is just one alcohol counselling centre with only three mental health professionals. Other factors hindering effective integrated case management in South Korea, in general, include insufficient training on case management or lack of supervision (Ham and Lee, 2011), mental health social workers’ short service career (an average of 27 months), a shortage of skilled manpower (Hwang, 2008), centre directors’ lack of understanding on the importance of case management, and an administrative system that minimises flexibility for much attention on case management (Min and Yim, 2014). These factors, in other words, suggest an absolute need for agencies to work towards aggressively developing and providing human and material resources to accommodate multiple needs presented by low-income individuals with mental illness.

Mental health professionals’ priorities were primarily their registered clients with mental disorders or very few referred clients; they, too, are excessively overwhelmed with serving the registered individuals with mental illness. Unfortunately, this made them unable to actively take inter-agency referrals, which was consistent with quantitative findings; agencies were collaborating on less than 10% of mental health cases. These findings reflect the current system, which lacks the mainspring of deinstitutionalisation, and contradicts the core objectives of case management: goals driven by the clients’ needs, not those of the system.

Other critical factors include the gap between supply and demand and non-mental health professionals’ distorted views of mental health workers. The unrealistic expectations of mental health professionals to ‘wave a magic wand’ or ‘fix everything’ has led them to experience considerable stress and contributed to feelings of helplessness due to not being able to aggressively respond to community needs. One remedy is to consolidate the current case management system by providing education on mental health and using screening tools to evaluate generalist social workers, who often encounter clients whose mental health may be questionable at the clinical level (Carter et al., 2015).

Such issues can be understood from the different background of the mental health system in Korea in comparison with Western countries, where the history of case management and utilisation is somewhat different. For instance, while the emergence of case management in the United States was based on the necessity to provide community mental health services to help the mentally ill population with multiple needs who were being ‘released into the community’ as a result of deinstitutionalisation in the 1960s, greater emphasis was put on the practitioners’ role as clinicians (Choi and Cheong, 2015).

In Korea, however, case management in the field of mental health began in earnest with the Mental Health Policy 1997 to actively assist individuals with mental illness within local mental health facilities. Thereafter, since 2000 case management has been performed as part of an official service delivery system in both public and private sectors to tackle various problems in the general population, particularly confronted by low-income families, including mental health issues, poverty, education attainment and violence (Kang, 2014; Min, 2015b). Unfortunately, this practice model targeting low-income individuals with mental illness is as yet immature in that there still lacks consensus among scholars and practitioners on the term and definition of integrated case management at both the national and local levels in Korea, resulting in lingering confusion and frustration. Moreover, as the Korean government has recently amended the mental health policy to aggressively target prevention services, not only has relatively less attention been given to case management on individuals suffering from severe mental illness (Min, 2015a), but also fewer professionals are available to assist low-income individuals with mental illness.

Second, a lack of collaboration and a low degree of inter-agency networking activities (at <10%) were considerable problems. Although the respondents (including mental and non-mental health professionals) described their attempts to provide skilled and reliable social services, in reality, their perceived level of management for individuals with mental illness was quite poor. Despite some agencies already having signed a memorandum of understanding with other agencies to cooperate at various levels, the contracts were not being transferred to a workable paradigm that would lead to practice. This implies that there are mentally challenged clients living without proper care for their mental health needs and many other needs as well. In turn, this may impact their ability to effectively care for themselves or become economically independent from the social service system.

However, the gap between what practitioners value in their work and their level of performance is somewhat understandable. This is because the success of integrated case management requires at least two actively involved parties, but more importantly, the current level or success of integrated case management in South Korea does not affect their individual evaluations or assessments of the agencies where they work. Hence integrated case management is considered extra work, not a top priority.

On another note, this phenomenon suggests that non-cooperative attitudes may have resulted in poor inter-agency collaboration. Thus, a standardised manual on integrated case management (which the informants unanimously suggested) is an important factor in developing a good system. Other specific ways to foster increased networking include conducting more inter-agency meetings about cases presenting multiple and complex needs, as well as providing external supervision and continuing education. This may be possible by utilising a pool of professionals who can provide and continuously monitor the quality of integrated case management (Jang et al., 2015; Sung, 2014).

Finally, the quantitative findings might make it seem as if there have been very few cases requiring mental health services. However, given the opinions of generalist social workers (shared in the focus groups) that they greatly need professional help for the mentally challenged yet that very few cases receive appropriate attention, the service exchange pattern illustrated in Figure 1 minimises their desire to collaborate more frequently and efficiently with mental health professionals, and vice versa. If they do not cooperate with each other, mentally challenged clients will likely be left without proper care, resulting in the failure to promote healthy lifestyles and continuous dependence on the system. Therefore, the quantitative findings may simply reflect the current state of integrated case management in South Korea: fragmented social services for individuals with complex needs.

Despite some interesting findings, this research is not without limitations. For example, this article mainly focused on presenting the qualitative findings of the study. Also, the spreadsheet used to quantify integrated case management was filled out by humans who may have been guided by their own perceptions and understanding of integrated case management. Therefore, there is a possibility of underestimating or perhaps overestimating true integrated case management in South Korea, particularly for cases of individuals with mental illness. In this sense, we suggest that there still remains the issue of a lack of national guidance on the term and the need to find a consensual agreement for future research.

To conclude, the findings imply a critical need for a workable paradigm, including developing a centralised system within communities (i.e. a control tower or an umbrella of services for people in mental illness), a stronger infrastructure, and a ‘sharing’ atmosphere for productive professional partnerships to facilitate lobbying and networking activities. This would be possible by establishing a functional organisation, such as a control tower, that can play a centralised role in building a stronger and more effective system for integrated case management. Key functions include (but are not limited to) (1) developing and disseminating human manpower and material resources, (2) continuing quality education for case managers on mental health and (3) initiating and monitoring integrated case management activities. These efforts would improve the lives of mentally challenged individuals and their families in assisting their multiple needs. These endeavours would also contribute to lifting practitioners’ stress levels and workload and strengthening the ability of system management to provide better professional care.

While study participants strongly suggested the need for a control tower to oversee integrated case management, there were least discussions on which party to take on the major role. Should it be a private sector, administrative competence and credibility may be at stake, while the public sector’s range of resources to carry out the operation may also rise as a considerable issue. A mental health centre comprises an interdisciplinary term of licensed mental health social workers, clinical psychologists and nurses, thus also making it difficult to function as a control tower. Then, a social welfare centre may be most suitable for this task, yet their primary job description does not include integrated case management; therefore, there is a slim chance of sufficiently providing effective services to meet the complex needs of the population. After all, it would be ideal for a third party, such as a social welfare foundation, to take on the centralised role, especially in South Korea where these foundations are newly formed in every local government and are independent from public and private sectors in function, as well as mental health centres, and independent of their mission and capable of managing community resources. In fact, local governments in South Korea are currently in the planning phase of developing a control tower that can encompass these roles (Park and Chang, 2013).

On another note, despite the critical and timely need for a control tower, if the control tower is incapable of proper functioning or plays a superior role only to become directive rather than being supportive or participatory, a variety of issues can arise. These may include confusion or poor motivation for participation as a result of inflexible networking, work overload in agencies or unnecessary overlap with existing work (Choi et al., 2014). Therefore, the importance of the control tower’s supportive role in the networking activities cannot be emphasised enough. Moreover, the control tower should be able to secure sufficient budget and an outstanding workforce to strengthen the Korean integrated case management system because, so far, inadequate budget and manpower in each participating agency have significantly hindered efficient service delivery (Gyeonggi Welfare Foundation, 2015). In this sense, the welfare foundation in each local government becoming the control tower makes most sense, being both appropriate and feasible.

In the application and merging process of a Western social service delivery system into a quite dissimilar Eastern sociocultural context and welfare system, trial and error, distress and innovative ideas are deemed necessary for adaptation and maturation. Because the Korean government has recently begun to encourage greater partnership across agencies, particularly between public and private sectors to better assist clients with multiple needs, this study is particularly meaningful in that it is the first to explore in-depth social workers’ experiences of integrated case management in assisting low-income individuals with mental illness, and is therefore able to suggest policy improvement for best social work practice.

Furthermore, the findings emphasise closer and voluntary partnership across agencies, in both the private and public sectors, given the current fragmentation of resources throughout the community. This is because, as previously mentioned, South Korea’s contemporary mental health care systems focus primarily on treating mental disorders only for the registered mentally ill population, and the lack of integrated case management in mental health settings has significantly impacted the workers’ ability to provide resources other than those that relate to mental health, which many complex cases present. In essence, improved integrated case management will greatly increase the quality of life of individuals and families suffering from mental illness.