Service Delivery and Outcomes of A Culturally Responsive Mental Health Intensive Case Management Program for Three Refugee Communities

Background and Purpose: Refugee communities face higher rates of serious mental illness and their access to services is often compromised by language barriers, stigma, and a lack of culturally responsive services.  Service provision for these communities has to reflect their particular needs.  An intensive case management (ICM) program in Toronto has been developed to serve people with serious mental illness from the Afghan, Tamil, and Somali communities, all of which are from war-torn regions.  This study has three objectives: 1) examining how the ICM service responds to specific needs of the three groups; 2) exploring factors that promote or create challenges during the service delivery process; and 3) assessing the service’s 2-year outcomes, including client employment, treatment compliance, residential status, and number of hospital visits.  

Methods:  The study adopted a mixed-method design.  Focus groups, individual interviews, and a review of agency archive data were used to achieve Objectives 1 and 2.  We interviewed a total of five case managers, eight case aides, and three senior administrators, and reviewed the agency’s mission statement, service pamphlets, and internal reports.  Thematic analysis was used to analyze qualitative data.  Triangulation between coders and member checking were used to ensure study rigor.  To evaluate the service outcomes (Objective 3), we conducted chart reviews of all clients enrolled between 2005 and 2010 and used paired t-tests to compare mean scores of outcome variables between baseline and 2-year follow-up.

Results: Qualitative results indicate that a culturally responsive ICM requires case managers to negotiate their roles with clients and their family, particularly for those clients from countries where the concept of case management does not exist.  Balancing boundaries and addressing issues of confidentiality are ongoing challenges case managers encounter.  Extensive psychoeducation for the family and widespread community outreach efforts (including to mosques and other spiritual places) are critical in facilitating program success, so is an active volunteer program that consists of trained community members who served as case aides.  Support from the upper administration and an agency culture on promoting diversity and service equality enhance staff morale, which in turn facilitate low staff turnover rates.  

Paired t-tests results based on 91 clients [69.2% females; mean age 41 (SD = 10.35) years] suggest that clients have better employment outcomes (p < .05; effect size [ES] = 0.47), improved treatment compliance (p < .05; ES = 0.54), and fewer hospital visits (p < .01; ES = -0.88) after receiving the service for 2 years.  Clients’ residential status remains unchanged.

Conclusions and Implications: An ICM designated for Afghan, Tamil, and Somali communities is effective in improving clients’ employment function and service use outcomes. To provide responsive services to clients from refugee communities, case managers need to be versatile in working with clients, their families, and their communities. This research yields important information for the design of effective and relevant mental health services and will serve to inform research, program, and policy development directed at improving mental health outcomes for refugee communities.