Managing Continuity of Care Through Case Coordination

Transcription

1 Managing Continuity of Care Through Case Coordination October 15, 2003 Principal Investigator: Dr. Heather Hadjistavropoulos 12 Research Manager: Cecily Bierlein 12 Co-principal Investigator: Sue Neville 2 Principal Decision Maker: Sharon Garratt January October / Linda Wacker Fall 2001 February Original Team Member: Dawn McNeil 2 Additional Team Members (alphabetical) Carolyn Bremner 2 Gretta Lynn Ell 2 Thea Jacobs 2 Mark Sagan 2 Research Assistants: Allisson Quine 12 Tandy White 12 Michelle Bourgault 12 1 Department of Psychology, University of Regina 2 Regina Qu Appelle Health Region 48

2 Funding provided by: Canadian Health Services Research Foundation Saskatchewan Industry and Resources - Innovation and Science Fund Regina Qu Appelle Health Region Contact principal investigator at: Dr. Heather Hadjistavropoulos Department of Psychology University of Regina Regina, SK Canada S4S 0A2 Telephone: (306) Fax: (306) hadjista@uregina.ca Acknowledgements: A sincere thanks goes out to Regina Qu Appelle Health Region clients, case coordinators, service providers, management and partners. This project was supported by a financial contribution from the Canadian Health Sciences Research Fund and the Saskatchewan Economic and Cooperative Development. The views expressed herein, however, do not necessarily represent the official policy of the federal, provincial or territorial government.

3 Table of Contents KEY IMPLICATIONS FOR DECISION MAKERS... II EXECUTIVE SUMMARY...III I. THE CONTEXT...1 II. PROJECT IMPLICATIONS...2 III. APPROACH...6 IV. RESULTS...10 CLIENT DEMOGRAPHICS...10 CLIENT RISK OVER SIX MONTHS...11 SERVICE USE OVER SIX MONTHS...11 CHANGE IN CLIENT MEASURES OVER THE SIX MONTH PERIOD...12 CLIENT SATISFACTION...13 ACTIVITY TRACKING DATA...13 CASE COORDINATION GUIDELINES...15 FOCUS GROUP EVALUATION...18 GUIDELINE REVISIONS...20 RESULTS OF PILOT IMPLEMENTATION...21 V. ADDITIONAL RESOURCES...22 VI. FURTHER RESEARCH...22 VII. REFERENCES...24 VIII. APPENDICES...26 APPENDIX A...26 Workload Tracking Form for Research Purposes...26 APPENDIX B...27 Case Coordination Guidelines...27 FORM 1 - TRACKING FORM FOR RESEARCH PURPOSES FORM 2 - PROFESSIONAL SERVICE PROVIDER FEEDBACK FORM TO COORDINATOR FORM 3 - SUPPORT SERVICE PROVIDER FEEDBACK FORM TO COORDINATOR FORM 4 -COORDINATION TRACKING (AGE 65 AND OVER) FORM 5 - QUALITY CHART REVIEW FORM 6 - QUALITY OF CASE COORDINATION QUESTIONNAIRE FORM 7 - CLIENT BROCHURE FORM 8 - SERVICE PROVIDER BROCHURE APPENDIX C...58 Focus Group Questions...58 APPENDIX D...59 Tables...59 APPENDIX E...67 Study Overview Pamphlet...67 i

4 Key Implications for Decision Makers Guidelines for case coordination set standards for how much time case coordinators spend with elderly clients requiring multiple community health services. Guidelines can increase consistency and accountability when managing continuity of care among community case coordinators. Participants agreed that focus on actual practice, rather than expected or preferred practice represents the best starting point for guideline development as it ensures that realistic timelines. Time and need based community case coordination guidelines benefit service delivery, program planning, staff supervision, performance improvement, education and training. Not all clients have the same coordination needs. Different case coordination guidelines are required for clients with low, some and high risk for institutionalization. Varying models of case coordination (e.g., brokerage versus service coordination model) need different guidelines. These guidelines are specific to a brokerage model of case coordination. Clients indicated their primary focus was on receiving a home assessment quickly in a caring manner. Therefore, parameters surrounding urgency of assessments should be added to community case coordination guidelines in order to meet this client focus. As risk of institutionalization increases, case coordination and home care service use increases as well as amount of contact with clients, family and service providers. The time allocated to clients of varying risk must be flexible enough to account for variables that can increase or decrease coordination time (e.g., support, dementia, poor health). Most regions consulted during the study supported reassessments based on need rather than arbitrary time frames. Many supported the idea of extending the reassessment time for low risk clients to as much as three years, as long as adequate monitoring of client needs was in place. Building in a consistent communication function (e.g. regular service reviews) between case coordinators and service providers is an essential part of improving continuity of care for clients. Educational materials are needed to inform clients and providers of the role of case coordinators to ensure appropriate understanding and optimal usage of case coordinators in assisting with care. High caseload sizes and fear of rigid application are predicted to impact effective implementation and usage of guidelines by coordinators. ii

5 Executive Summary Community case coordination assists elderly clients requiring community-based health care to receive community services and reduce or delay the use of acute care and long term care. Case coordination typically involves assessment of client needs, care plan development and implementation, monitoring of service provision, and reassessment. Despite the general framework of these case coordination activities, perceptions of case coordination often differ considerably, particularly in regard to the nature and frequency of coordination services. In addition, the amount of case coordination is not always adequately linked to the level of need of the client. The purpose of this project was to develop guidelines for community case coordination that were linked directly to the client s level of need. In order to increase the utility of the guidelines, the goal was to base these guidelines on actual practice as opposed to preferred practice. Data was collected on community case coordinated clients over the age of 65 beginning at the time of their initial referral to case coordination. The client s level of risk was determined by application of the Regina Risk Indicator Tool 1. Case coordinators completed a workload tracking form over a six-month period on each of the clients in the study. After examining actual case coordination practice as a function of client s level of risk, guidelines were drafted by an expert panel of case coordinators, decision makers and researchers. A series of focus groups including clients, service providers, and decision-makers evaluated the guidelines. A brief tracking form based on the draft guidelines was subsequently piloted in May and June of 2003 and feedback used to form the final guidelines. Implications This study provides objective data for use in better understanding case coordination of community health services for elderly community dwelling clients. Guidelines can be used to reduce inconsistency in case coordination delivery and to improve accountability. As well, the guidelines iii

6 increase awareness of current case coordination practice to those not directly involved in case coordination. Decision-makers can use this objective data to use in program planning and to gain a greater understanding of resources needed for case coordination. The guidelines can assist with the education and training of new case coordinators by establishing benchmarks to guide practice. The guidelines may also be used as a quality measure, to ensure fair and consistent case coordination both on an individual and aggregate level. The specific times and ranges developed will likely vary by region as well as by the case coordination model employed (e.g., brokerage vs. care based), but the method and format of developing guidelines could be applied to any region or other client populations. Project Results This project resulted in the development of case coordination guidelines which specify ranges of coordination time and frequency of contact with elderly clients based on levels of risk (low, some, high). The screening tool that correlated most strongly with case coordination time was the Regina Risk Indicator Tool (RRIT), and this tool was used as a basis for developing guidelines into three different levels of risk. Data analysis revealed that the majority of new referrals to case coordination exhibit low or some risk of institutionalization (RRIT). However, those clients exhibiting higher risk of institutionalization used more case coordination time and more home care services on average. The data gathered on case coordination time revealed that the majority of case coordination occurs in the first month for assessment, plan development, and plan implementation activities, and then tapers off thereafter into a monitoring function. Participants who were consulted in this study encouraged a wide range of case coordination time to allow for professional judgement and for individual client variability. Also, case coordinators requested lengthening the amount of time between scheduled full reassessments for low need clients (e.g., three years instead of one year), as reassessing low need clients annually was felt to be iv

7 inefficient. To ensure clients were appropriately monitored for changes in their health or support status, routine service reviews were built into the guidelines at three months for new clients and one year thereafter. In addition, the guidelines specify that when clients experience significant change in functioning, service use, or social support, the coordinator initiates a service review or a full reassessment to ensure the clients changed needs are fully understood and appropriately met. Identified Barriers to Success and Recommendations Analysis of focus groups demonstrated that potential barriers to implementation of guidelines included fear of rigid application, disconnection between coordinators and service providers, need for staff buy-in, increased paperwork, and high caseload sizes. To address these concerns, the guidelines were emphasized as a supportive tool with scheduled service reviews to foster greater communication among coordinators and service providers. Staff buy-in was achieved through inclusion of staff in the development process, a pilot implementation, and continuous feedback. Paperwork was kept to a minimum through the addition of only one new activity tracking form and one service provider form. High caseload sizes were taken into consideration by tracking only a small portion of clients at any given time. Parameters for urgency of assessment were also added, as the importance of this aspect was clearly identified by clients. In summary, we recommend that guidelines for case coordination are necessary in order to ensure consistency and quality of service delivery. Guidelines must be based on actual practices and available resources, not preferred arbitrary standards. Guidelines must be flexible in order to allow for variation within need levels, but not be so wide in range as to be meaningless in setting expectations for service delivery. Development of effective guidelines also requires the involvement of case coordinators, clients, service providers, and decision-makers. Finally, by gathering information about case coordination, a better understanding and appreciation of the nature and importance of case coordination is achieved by client, service providers, and decision makers. v

8 I. The Context Case coordination involves the coordination of care for clients through such characteristic functions as needs assessment, care plan development, plan implementation, monitoring of progress towards care plan goals, and reassessment. The purpose of community case coordination of elderly clients is to assist clients with chronic functional limitations to maintain independence in the community by coordinating support from service providers 1. Community coordinators also assist with continuity of care and help clients navigate their way through fragmented health care services. Many clients, service providers and decision-makers have differing or unclear understandings of the specific nature of case coordination services and do not know what to reasonably expect from case coordinators. Although case coordinators may agree on a client s need for services, they may disagree about the amount of services required by the client 2 and the amount of time the case coordinator should spend in facilitating the provision of those services 3, including amount of attention to needs assessment, care plan development, implementation and monitoring. Case coordination guidelines can encourage consistency of practice, match case coordination services to client need, establish realistic expectations of coordinator responsibilities, assist with time management and training, allow for resource planning, and aid in quality review. Most literature regarding community case coordination is descriptive and provides little information about the factors that increase case coordination time 4. The case coordination guidelines that currently exist describe the basic processes involved in case coordination: assessment, care planning, monitoring, reassessment, and discharge 5,6,7. Although the majority of these standards appear to agree on the general nature of case coordination, applications of these standards to specific populations are difficult to find. This generic approach often does not reflect the real nature of case coordination, as most work is affected by the specific needs of the client population, as well as organizational and system issues 8. Some state and provincial standards 9 are more specific in their 48

9 description of the length of time between intake and assessment, or between assessment and reassessment, but often do not address the specific amount of case coordination time required, the intensity of case coordination, and the factors that can increase the need for additional case coordination time. Matching the intensity of case coordination to client need is a crucial task, yet few have developed or even studied case coordination time requirements for specific client groups 10. The research that has begun to address need-based case management guidelines has divided clients into acuity groupings, moderating the level of case management given to each group 11,12,13,14. For example, Quinn, Prybylo, and Pannone 11 divided clients into six acuity levels, matching service to acuity levels. An Ohio study divided clients into Basic Assistance, Ongoing Service and Case Management 12,13. Another model provided assessment and intervention planning for intense community care management, changing the type of care as the client stabilized 14. Building on the idea of tailoring case coordination to the client s level of need, this study systematically developed guidelines for community case coordination of elderly clients that specify the nature and frequency of coordination, based on the client s level of need. In addition, the study evaluated these guidelines from the perspective of various stakeholders. II. Project Implications Implications for Decision Makers 1. Based on the data collected, different guidelines are required for clients with differing levels of risk of institutionalization (low, some or high). Not all clients have the same coordination needs. 2. As risk of institutionalization increases, case coordination time increases, and home care service use also increases. Contact with clients, family and providers also increases as risk level increases. 2

10 3. Participants agree that for guidelines to be feasible they need to be based on actual practice, not on expected or preferred practice. Without information about actual practice, unrealistic guidelines are likely to be unrealistic and unattainable. 4. The guidelines must have a wide enough range to account for client variability and the effect of key variables that can influence coordination time (e.g., social support, dementia, poor health) 5. Time and need based guidelines provide objective data for decision makers to use in program planning, supervision, performance development, education and training, and quality review. 6. Most coordination time occurs in the first month during the assessment, plan development, and plan implementation phases. Therefore, guidelines need to specify how often the case coordinator will review the client file and have contact with providers following that first month in order to ensure adequate continuity of care. Guidelines also need to specify what triggers should be used to alert the coordinator that additional attention may be needed. 7. High caseload sizes and fear of rigid application are potential barriers to acceptance and implementation of guidelines. To overcome these barriers, it may only be feasible to track a certain percentage of a caseload so as not to add undue workload for coordinators. 8. The guidelines should be a supportive tool for purposes of self-monitoring, quality improvement and performance enhancement, rather than absolute standards. 9. Guideline-related tools improve use of guidelines. For example, a tracking form helps coordinators use the guidelines, and client and provider brochures ensure a common understanding of case coordination. Provider feedback forms assist with review and monitoring of cases, while a Case Management Quality Questionnaire (CMQQ) monitors client satisfaction with coordination. Last, a chart audit form helps managers monitor use of guidelines. 3

11 Implications for Case Coordinators 1. Time and need based guidelines provide an opportunity for case coordinators to reflect on their practice and how closely it fits within established norms. 2. Community case coordination guidelines provide case coordinators an opportunity to better communicate with service providers and clients in order to foster realistic expectations of case coordination service. 3. Guidelines also serve as an excellent means of communicating with decision makers, who are removed from the actual practice of case coordination, about the intensity of time and requirements entailed in effective case coordination. 4. Guidelines will be of great assistance in training new case coordinators about the time requirements for effective and efficient case coordination of clients with varying levels of risk. 5. Preference was given to client need being the justification for when to complete a reassessment, rather than following arbitrarily pre-determined time frames. 6. Although tracking of all clients to ensure they receive care according to guidelines would be ideal, this is not feasible given time requirements for monitoring. Implications for Services Providers 1. Community case coordination guidelines facilitate realistic expectations and improved understanding about case coordination for the service providers. One way to share this information is through brochures for providers. 2. Building in communication through regular service reviews between service providers and case coordinators is an essential part of increasing teamwork and communication in a brokerage model of case coordination. 4

12 Implications for Clients and Caregivers 1. A satisfaction questionnaire implemented annually assesses client satisfaction with case coordination. From the data collected, clients desire more frequent contact with their case coordinators, want delays explained, and want more frequent review of their service needs. 2. Clients desire quick and timely assessments from case coordinators. Parameters specifying prompt and responsive timeframes from referral to assessment meet the clients need for timely assessments, and prioritizes assessments based on urgency. 3. Communicating information to clients about time and need based guidelines as well as the role of case coordination can foster improved understanding and realistic expectations of coordination. One way to share this information is through client brochures. Implications for Other Regions 1. Guidelines will vary depending on the model of case coordination used. In this study, the brokerage model was used in which case coordinators do not provide services (e.g. nursing, therapy) themselves; these services are brokered by the coordinator on the clients behalf. In regions where case coordination and service provision are combined, the guideline amounts would need to be adjusted to account for a different model of case coordination service delivery. 2. The regions outside of Regina agreed that information on current case coordination practice is of value when communicating with decision makers, service providers, and clients regarding the extent and nature of case coordination services. 3. Participants also agreed that case coordination guidelines should be based in actual practice. 4. The method used in this study could be used in other settings for developing guidelines and time ranges appropriate to those particular environments and populations. 5. Tools developed to support the guidelines could be used by other regions (e.g. tracking forms, CMQQ, provider feedback forms, brochures). 5

13 III. Approach Client Interviews At the time of referral, intake coordinators asked clients aged sixty-five and over if they were interested in participating in the study. Those interested were contacted by phone and given further information about the study. If still interested, a personal interview with the client was scheduled, which usually took place in the client s home approximately twelve days after the coordinator had visited for an assessment. When a client was determined unable to consent for himself or herself, consent was obtained from a family member. Clients were asked a variety of questions relating to mental status, physical and emotional health, social support, risk of institutionalization, and satisfaction with case coordination. Permission was also obtained to access medical files, including data regarding services utilized and case coordination information. Six months after the first interview date, a second interview was arranged with the client and the same questions were asked again. Of the original cohort, 71.4% of the clients were still receiving case coordination services after six months. The remaining clients were discharged because their health or supports improved, they had left the region, or they died. Whenever possible, clients who were discharged early were interviewed shortly after their discharge. Several standardized measures were used during the interviews. A brief description of each is given in the following paragraphs. The Regina Risk Indicator Too1 is a 23 item tool that is used as an aid in assessing risk of institutionalization and/or risk of high service utilization. Previous research has shown good interrater reliability, internal consistency, and known groups validity 15. Mini Mental Status Exam (MMSE) is an 11 item widely used cognitive test used to screen for presence of dementia 16. Previous evidence has shown that the MMSE exhibits good test-retest and inter-rater reliability, as well as high internal consistency 17. 6

14 Short Form-8 (SF-8) is a health status instrument consisting of eight items that produce separate scores for physical and mental health. The SF-8 has been shown to have good internal consistency, test-retest and inter-rater reliability, and known groups validity 18. Duke Social Support Index, Abbreviated (DSSI). This study used a 23 item abbreviated version to measure essential components of social support, producing a total score and three subscales: Social Interaction; Subjective Support; and Instrumental Support 19. Previous research has shown the DSSI to have good test-retest reliability, inter-rater reliability, and concurrent validity 19. Case Management Quality Questionnaire (CMQQ). This 30-item tool was developed for the study to measure client satisfaction with community case coordination. The tool assesses accessibility, efficiency, and assessment/coordination skill. Initial findings reveal that the CMQQ has excellent internal consistency and concurrent validity 20. Activity Tracking During the six months that each client was involved in the study, the assigned case coordinator tracked the case coordination time required for that particular client. This tracking was completed through the use of an activity tracking form for research purposes (Appendix A) attached to the front of the file. Every time the case coordinator carried out a case coordination activity, the date, nature of the activity, and the time required was recorded. The activity carried out was broken down into the following dimensions: phase of case coordination (e.g. assessment, plan development, plan implementation, monitoring, reassessment, and discharge), type of activity (e.g. in-person, telephone call), with whom the contact took place or to which the activity was directed (e.g. client, family, service provider) and time in minutes (rounded to the nearest five minute span). Additional space was allowed for comments and complex circumstances. The form was designed for ease of use by using a multiple choice selection format instead of numbers codes, tracking time in minutes instead of units, and the inclusion of easy to understand abbreviations listed at the bottom of the 7

15 form. Prior to the commencement of data collection, all case coordinators were trained how to use the form and given an instruction sheet for reference. In addition, a Research Associate was on-site to answer questions and monitor use of the form. Service Use Data Home care service use, long term care service use (Adult Day Support, Respite, Quick Response Unit, Convalescent Care), as well as hospitalization and emergency room use was obtained from Regina Qu Appelle Health Region databases over the six month period for each client. Guideline Development Correlations were examined between variables measured (e.g. mental status, social support, health status) and case coordination time. One-way Analysis of Variance was used to determine if case coordination varied as a function of group status (e.g. low, some or high risk). At the end of this analysis, the Regina Risk Indicator Tool (RRIT) was determined to be the best overall tool that related to case coordination time; clients of varying risk were found to differ in amount of case coordination time. The client population was then divided into client subgroups based on the RRIT tool (low, some, high risk) for guideline development. Draft guidelines were developed, incorporating specific case coordination time per case coordination phase for each client subgroup. An expert panel of case coordinators, decision makers, and researchers reviewed and revised the draft guidelines. In addition, service review parameters and response timeframes were developed, and consideration given to an extended timeframe between reassessments conditional to adequate monitoring. A draft of the proposed guidelines was created, as well as a revised activity tracking form (Appendix B, Form 1) which incorporated the specific time ranges and client subgroups. While developing the guidelines, it was apparent that other tools would be needed to facilitate usage, including a service provider reporting form, client brochure, service provider brochure, and quality improvement chart audit form (Appendix B). 8

16 Guideline Evaluation The draft guidelines were evaluated through a series of focus groups. Each focus group was asked a similar set of questions regarding benefits of the guidelines, negative aspects of the guidelines, barriers to implementation and suggestions for revision (Appendix C). In the Regina Qu Appelle Health Region, separate focus groups were conducted with clients, caregivers, home care service providers, case coordinators, and decision makers. In addition, focus groups with case coordinators and decision makers were held in Calgary, Alberta; Edmonton, Alberta; Saskatoon, Saskatchewan; and Waterloo, Ontario in order to assess the external validity and applicability of the of the guidelines. At the end of the focus groups, the data was qualitatively analyzed with N-6 software. The main themes from the focus groups were divided into benefits and suggestions and presented to the original expert panel for consideration, resulting in final revisions to the guidelines. Pilot Implementation A two month pilot implementation of the guidelines and tracking form occurred in May and June of Case coordinators each tracked ten new clients and ten ongoing clients. In addition, case coordinators began initiating the Client Services Update forms, to elicit information from service providers. Structured interviews were completed with thirteen coordinators at the end of the pilot implementation and further revisions made to the tracking form. Dissemination Events at which presentations have been made or are scheduled: September 25-27, Case Management Conference, Saskatoon, Saskatchewan March 19, Presentation to Saskatoon Health Region, Saskatoon, Saskatchewan April 3, Presentation to Calgary Health Region, Calgary, Alberta April 4, Presentation to Capital Health Region, Edmonton, Alberta May 21-24, th Conference on Gerontological Nursing, Kelowna, British Columbia 9

17 June 10, Presentation to Waterloo Health Region, Waterloo, Ontario June 20, Presentation to Regina Qu Appelle Health Region, Regina, Saskatchewan October 26-29, International Conference on Care Management, Philadelphia, Pennsylvania November 30 Dec 2, Canadian Home Care Association Conference In addition, results were mailed out to most Health Regions in Canada and some United States locations in an easy to read, colorful pamphlet (Appendix E). Feedback was also given to clients in a mailed out letter and client brochure. The Regina Qu Appelle Health Region disseminated results though an on-line staff newsletter, client newsletter, physician newsletter, and quarterly report. IV. Results Client Demographics A total of 622 people age 65 or older were potentially eligible for participation in the study during the recruitment time frame of October 2001 to May of 2002, with final data completion by December of Recruitment was based on consecutive referral to community case coordination for multiple community services. Of the 622 clients, 60 declined a case coordination assessment, and 35 did not require case coordination shortly after referral for the following reasons: immediately entered long term care (16); died (10), hospitalized for an extended period of time (3); only received one home care service without being case managed (3); moved out of the region (2); and could not be located prior to being invited to participate (1). Of the remaining 527 referrals available for the study, 234 client participants were recruited for a participation rate of 44%. Client demographics for this study sample included more women (66%) than men, and an average age of 80 (SD=7.38) years, ranging from age 65 to 101. Nearly half of the participants were widowed (48%), with 40% married, and the remainder single, separated or divorced (12%). In 10

18 addition, most clients had stable social support (84%), while the remainder (16%) had unstable or no significant social support. Stable social support was defined as having a partner or caregiver who is emotionally prepared and physically able to provide support to the client, whereas unstable social support was defined as having a partner or caregiver emotionally stressed and/or physically unable to provide support. The majority of participants lived in their own home during the course of the study (86% at the first interview, 77% at the second interview). However, over a period of six months, there was a 9% reduction overall in the number of clients living in their own home, with the number of clients requiring placement in a Personal Care Home increasing by 5%, and the number of clients in long term care facilities increasing by 2%. Further demographics are detailed in Table 1 of Appendix D. Client Risk Over Six Months The majority of clients in the study displayed either low or some risk of institutionalization at both the first (low = 53%, some = 36%) and second interview six months later (low = 65%, some = 20%). After six months of case coordination services, 25% of the participants decreased in risk of institutionalization, 54% stayed at the same risk level, and 21% increased in risk. Average risk of institutionalization (RRIT) overall was lower at the six month interview (F (1, 179) = 4.95, p<.03). Service Use Over Six Months Average home care (HC) use equaled 4.8 hours per month, with the following services being the most commonly used at least once by the clients during the six-month service span: occupational therapy (69%); nursing (41%); and homemaking (40%). However, the largest average hours used over the six month period was for homemaking (31.65 hours, n = 94) and nursing (19.84 hours, n = 38). Table 2 in Appendix D outlines specific service use data. When separated by risk category, participants with higher risk of institutionalization used more HC services (low=16.6, some=37.2 high=49.8; F(2,199) = 9.28, p<.00). This data illustrates the need 11

19 for closer monitoring of clients who are at high risk, than for those at low or some risk. Specific service use hours by risk level are detailed in Table 3 in Appendix D. Few participants accessed long term care (LTC) support services such as day programs, quick response beds, or convalescent care. Of LTC programs, convalescent beds were used most frequently (9%), with an average stay of 31 days for those admitted. Approximately 26% of the participants were hospitalized over the six-month period, with an average stay of 23 days (SD=21.92). However, further analysis revealed that 34 % of those hospitalized were waiting for LTC community-based programs (such as convalescent care) to become available. Twenty-seven percent of the participants accessed the emergency room at some point during the six months. Change in Client Measures over the Six Month Period Client status over the six-month period is reported in Table 4 of Appendix D. Over the six months, cognitive status (MMSE) did not change significantly (F(1, 174) =.03, p <.87) 21. In contrast, both physical health scores (F(1, 169) = 19.19, p <.001) and mental health scores (F(1, 169) = 18.95, p <.001) improved between the first interview and the second interview. However, physical health remained below the norms for this population age group, indicating a client group with poorer health than their same-age peers, whereas mental health scores reached the population norms at the six-month interview 18. Social interaction (F(1, 177) = 4.53, p <.04), and instrumental support (F(1, 175) = 10.48, p <.001) significantly decreased over the six month period, however, subjective support (perception of support) revealed no significant change (F(1, 176) =.02, p <.88). The lack of change in perceived support suggests an overall stability in social support, although scores were still below the norm, which may be a concern 22. Although social interaction and instrumental support decreased, this factor may be explained by less contact with caregivers as health improved. 12

20 Client Satisfaction The Case Management Quality Questionnaire (CMQQ) measures a total satisfaction score, as well as three subscale scores of accessibility, efficiency and assessment/coordination skill. The total score and subscales remained relatively stable over the six-month period (Table 5, Appendix D). The mean total CMQQ score at Time 1 equaled out of 30, with higher scores in the Efficiency (3.95 out of 5) and Assessment Coordination Skill (9.35 out of 11) subscales compared to Accessibility (7.12 out of 14). When asked specifically about satisfaction with case coordination on the CMQQ, most clients indicated they were satisfied with their case coordination at the first interview (94%) and at the second interview (91%). In addition, most clients felt that the services they received met their needs, and felt that the coordinator was caring (96%). However, some clients desired more contact from their coordinator (25%), wanted delays to be explained (30%), and desired the coordinator to review their needs more frequently (43%). Refer to Tables 6 and 7 in Appendix D for more specific satisfaction data. Activity Tracking Data Activity tracking data revealed that the average case coordination time spent over six months on each client was 5.15 hours, ranging from 35 minutes to 24.2 hours, with a median of 4.1 hours. The majority of clients (71%) received between 2 and 6 hours of case coordination time, while the remainder of clients (26%) received between 6 and 26 hours of case coordination time. Overall, those 26% clients accounted for approximately half of the total measured coordination time. This data exhibits that not all clients have equal case coordination needs. To assess validity of the tracking, a sample of 24 cases was randomly selected for audit in which tracking entries were compared to the written progress notes in the chart. Missed tracking entries estimated from review of the progress notes were calculated based on file notes, and it was determined that there was a 94% overall correspondence between the chart and the tracking form. 13

21 Case coordinators spent the majority of their time in activities in the first month, tapering Graph 1. Average Coordination Time Per Client by Month (n = 234) off both amount of case coordination and the number of clients receiving case coordination in Month 0 Month 1 Month 2 Month Month % 75% 50% 25% 0% Month Month 5 6 % of Clients Avg Minutes Per Active Client later months (Graph 1). Sixty-four percent of the total case coordination activity took place in the first month, with 100% of clients receiving case coordination in the first month, 55% in the second month, and 42% in the third month, declining to only 18% of clients requiring activity in the sixth month. In regard to phases of case coordination, the most case coordination time was spent in the assessment phase (average of 117 minutes for 97% of cases), followed by plan development (average of 69 minutes for 91% of the cases) and plan implementation (average of 69 minutes for 78% of the cases), followed by monitoring (average of 60 minutes for 67% of the cases). The most activity time was spent in in-person contact (32%), followed closely by paperwork (30%) telephone calls (24%), and travel (10%). Coordinators spent the most time in contact with clients or family members (50%) followed by health region service providers (40%), and multiple contact meetings (6%). Participants with higher risk of Graph 2. Average Case Coordination Time by Phase by Risk Level, Months 0-6 institutionalization used more coordination time 2 Minimal/Low (0-14), n = 124 Some Risk (15-20), n = 83 At/High Risk (21+), n = 27 on average, ranging from 4.6 hours in the minimal risk category to 8.3 hours in the high- Hours 1 risk category. Participants with higher risk levels 0 Intake Assessment Plan Dev Plan Imp Monitor Reassess Discharge Other specifically took more case coordination time in Months 1 (F (2, 230) = 7.35, p <.001) and 2 (F (2, 126) = 5.65, p <.005). Participants with higher risk levels also took more case coordination time 14

22 (Graph 2) in the assessment (F (2, 224) = 6.82, p <.001), plan development (F (2, 209) =.5.17, p<.01) and plan implementation phases (F (2, 179) = 10.30, p <.001). Table 8 in Appendix D outlines how classifying the clients by RRIT level (low, some, high) results in significant differences in the amount of case coordination time required for the different phases. In addition, participants with higher risk levels required more case coordination time for contact with family members (F (2, 160) = 3.78, p <.05), and service providers (F (2, 229) = 13.03, p <.001). Case Coordination Guidelines Case coordination guidelines were developed through analysis of the activity tracking, client interview, and service use data. Case coordination time, in particular, was analyzed by examining the mean, median, standard deviation and range of hours spent per month on the phases of case coordination. The study analyzed the ability of the various measures and variables to differentiate the case coordination time required. The RRIT (Regina Risk Indicator Tool) was found to be the tool that best differentiated between clients requiring varying levels of case coordination. As such, the guidelines match levels of client risk with the specific functions of case coordination and outline a range of time for varying activities for clients at low, some and high risk. To allow for variation in individual cases, case coordination time for each phase of case coordination over six months was defined by the median time and the range of time from the 15 th to 85 th percentiles (Table 1). The lower, medium, and upper range values were also rounded to the nearest five-minute interval for ease of use. 15

23 Table 1: Case Coordination Time Frames by Risk Level Case Coordination Activity Total Hours Assessment Plan Dev Plan Imp Monitoring Reasmnt Minimal/Low Risk Median Time over 6 4 hrs 100 min 50 min 40 min 30 min 80 min months Range of Time over hrs min min min min min months Some Risk Median Time over 6 5 hrs 120 min 70 min 70 min 50 min 80 min months Range of Time over hrs min min min min min months At/High Risk Median Time over 6 6 hrs 140 min 90 min 90 min 70 min 80 min months Range of Time over hrs min min min min min months Note: Based on the brokerage model of case management with a caseload between

24 In addition to the median time and ranges, an expert panel of case coordinators, decision-makers and researchers developed guideline instructions for response time from intake to assessment interview, frequency of review, and triggers requiring monitoring of clients. Service guidelines for coordinators are detailed in Appendix C. Implementation of these key activities will improve coordination and thus continuity of care: Case coordinators will complete a monitoring review at three months, annually, and at specified trigger points for supportive, long-term community clients. The coordinator reviews recent file documentation and contact notes, contacts service providers, and makes additional contact with the client, family or service provider as needed. Service providers (day support/respite/home care/pch operator) will send written updates to coordinators at three months and one year from the coordination assessment date, or at specified trigger points, for supportive, long term community clients. Monitoring reviews for short-term clients will be completed based on specified target dates calculated from assessed need and the specific service plan. The coordinator will complete a monitoring review at specified target dates by reviewing file documentation, contact notes, and the information received from the service providers. Full reassessments will be completed annually for some and high risk clients and every three years for low risk clients. Full reassessments will also be completed when any trigger for case coordination monitoring occurs for which the coordinator does not have adequate information to proceed without an in-person assessment. A telephone completion of the RRIT will be completed annually with low risk clients to determine if a full reassessment is needed. Cases with extreme (above or below guideline amounts) coordination time after six months should be reviewed by the coordinator with the supervisor. 17

25 Procedures to Monitor Quality and Continuity The expert panel also added quality measures to the guidelines to ensure a means to measure and track case coordination. As such, the Case Management Quality Questionnaire will be administered annually (in Guidelines document, Appendix C) to a random sample of clients on each coordinator s caseload. A quality chart review (Appendix C) will be completed in January and July to measure response times from the referral to start of service delivery, if the care plans reflect the need for services, and if the amount of case coordination is consistent with the guidelines. Focus Group Evaluation The draft guidelines developed by the expert panel were presented to focus groups of coordinators, clients, service providers, and decision makers to elicit comments and feedback. The results were analyzed under the themes of Positive Comments, Negative Comments, Barriers to Implementation, and Suggestions for Revision. Positive Comments The most frequent positive comment about the guidelines was that the guideline data gives concrete information about case coordination. A case coordinator stated, you look at these and you can certainly get a really good time frame picture and that sends a very concrete message. I think that would be extremely helpful. Focus group members also thought that efficiency and the communication mechanism between service providers and case coordinators were potentially positive impacts of the guidelines. Other participants noted the benefits of the guidelines for training and education. A case coordinator states that, I think some of the guidelines are really quite beneficial, particularly for new staff, because a lot of the new staff will comment when they re orientating well how long do you think this should take? How long do you think I should be spending? Participants discussed the benefits of consistency in service delivery, while supporting the need for large time ranges. A coordinator in Edmonton commented, I think there needs to be a range otherwise it becomes too narrow and too focused. Some case coordinators also thought 18

26 that supervision would be enhanced by having the guidelines to define expected service delivery, and also thought that case conferences were validated through the guidelines. Negative Comments By far the most common negative comments about the guidelines involved increased workload. A case coordinator in Regina says, if they have to go through a huge reporting mechanism its gonna take time away from the client which is not the purpose here. Several participants commented about the difficulty of quantifying case coordination. A coordinator in Saskatoon stated, I think clients don t fit into these boxes and it s always a challenge when you do something like this. Another common negative comment related to a lack of a client focus, as participants noted that the guidelines seemed administrative and didn t take into account client needs. Other participants commented that the guidelines were based on actual practice and should be eventually based on best practice, while others commented on the lack of more frequent reviews. Barriers to Implementation Fear of a rigid application was a very common theme mentioned in regard to barriers for implementation. A case coordinator in Edmonton stated, That s my concern. That [management] interprets them to be just hammering down. Another common barrier mentioned was the disconnection between the service provider and the case coordinator. A decision-maker in Regina notes that there are people out there in the home with eyes and ears, but unless you communicate with them you don t know what they are saying and hearing. Other participants recognized staff buy-in as a barrier to implementing the guidelines, while others mentioned unnecessary assessments taking up too much time. Case coordinators also commented on paperwork and high caseload sizes as a barrier to implementing the guidelines. One coordinator in Regina explained, Well, I just feel as though we re working in an age where you re just doing your casework on the next file. The next file. The next file. And it s hard to get a chance to be able to look at a particular case. Is the work I m doing really fitting within these guidelines or am I way off base? 19

27 Suggestions for Revision The most commonly occurring theme for revision involved adding a client focus to the guidelines (e.g. ask clients what is important to them). When clients were asked what most mattered to them about case coordination, they said that they wanted quick assessments. One client says, the assessor must go out to the client very quickly, yes! I came home without knowing about washing myself, washing my hair cooking at the stove with the oxygen - those are things I didn t know and I was frightened. The second most common theme recommended clarification of the roles of coordinators and service providers when they review the client s needs at three months and one year. Some participants also recommended adding more coordination time or frequency of contact to the guidelines. Guideline Revisions At the end of the focus group data analysis, the expert panel reviewed the data, and decided that: 1. The panel needed to reinforce the guidelines as a supportive tool, without rigid application. 2. The guidelines needed to become more client focused. Since clients stated that quick assessments were the most important aspect of case coordination for them, urgency of assessment parameters were added to the guidelines (Appendix C). 3. Although some focus group participants recommended guidelines based on best practice rather than actual practice, the panel decided to keep the guidelines as actual practice in order to keep them realistic and achievable. In a similar manner, although some participants recommended more frequent reviews, the review parameters were kept at the same time frames in order to be realistic given current caseloads. In practice, it would not be possible to increase the frequency of contact or time per client without substantial addition of resources (e.g., hiring additional coordinators) or drastically changing the current service model, both of which fall outside of the scope of this study. 20

28 4. An emphasis on teamwork between service providers and case coordinators was deemed to be essential to the success of the guidelines. The necessity and frequency of case conferences and team meetings was discussed. Case conference parameters were added to the guidelines, revolving around specific client issues (Appendix C). 5. The research team needed to minimize additional paperwork and workload strain as much as possible in the implementation of the guidelines. The panel decided that only one tracking sheet would be added to workload of the coordinators, and this tracking form would only be completed on a select number of cases, rather than the whole caseload, at least in initial implementation. 6. The service provider feedback form was also implemented as it was seen as a necessary part of communication between the service provider and case coordinator. 7. The panel further recommended that the roles of coordinators and service providers at service reviews be clarified. 8. The panel decided that the ranges of time would stay large, as most coordinators requested large time frames to allow for client variability and professional judgement. Results of Pilot Implementation A two-month trial of the revised tracking form and a pilot client services update form completed by service providers was implemented in May and June of Case coordinators tracked ten new referrals and ten existing clients over the two-month period. At the end of this period, structured interviews were completed with twelve coordinators, asking what was helpful and what was least helpful about the forms, and what could be revised. Through this process, the coordinators stated that they wanted a simpler activity tracking form, and the form was revised to its final version (in Guidelines document, Appendix C). 21

29 V. Additional Resources Published Articles Hadjistavropoulos, H.D., Sagan, M., Bierlein, C., Lawson, K. (2003). Development of a Case Management Quality Questionnaire (CMQQ). Journal of Case Management (4) 1, Journals to which articles have been submitted or plan to be submitted Reliability and Validity of the Regina Risk Indicator Tool for Use Among Case Managed Elderly Clients. Submitted to Health Care Management Forum. A Profile of Case Managed Elderly Clients and Service Use over Six Months. Submitted to Submitted to the Canadian Journal on Aging. Linking Guidelines to Risk of Institutionalization and Case Coordination Time. Submitted to the Journal of Case Management. Measuring Case Coordination: Who, What, When and How Much. Submitted to the Journal of Case Management. Web Site Release Study Tools and Forms The following tools and forms are available upon request: 1) Study Summary pamphlet 2) Full Guidelines Document 3)Client Brochure 4)Service Provider Brochure 5)Workload Tracking Form 6)Provider Feedback Forms 7)Case Management Quality Questionnaire VI. Further Research Limitations of Study One limitation of this study was that the population sample included only those clients over the age of 65. Community case coordinators also work with clients under the age of 65, and these 22

30 guidelines cannot be applied for those clients. In addition, this study only tracked the first six months of case coordination. As such, this data does not reflect a true workload, which would capture work with clients at any point in their service history. However, the methodology and tools used have been validated, and future studies of clients beyond the six month point of service will be able to address these questions. In addition, although there may be other tools that better differentiate case coordination, we were unaware of any such tools. Further study involving other tools that differentiate case coordination time may yield different results. Also, these guidelines are specific to the model of case coordination in the Regina Qu Appelle Health Region. Decision makers from other health regions would need to tailor the guidelines to their specific settings. Future Directions Future research could potentially examine the development of guidelines for clients of all ages as well as for longer periods of time. Perhaps at that point, analyzing caseload intensity through case mix and caseload size would be possible. Further research can now examine the benefits and challenges that result with full implementation of the guidelines. In particular, it will be important to examine if the guidelines will in fact: 1) improve services for clients including health outcomes and continuity of care, 2) improve communication among providers, 3) improve management of case coordination such as consistency, equity and training. Other areas for research include study of strategies for improving usage of the guidelines, such as automation of the tracking form onto a centralized database. Finally, it is apparent that guidelines will be helpful in improving continuity of care in that they set standards for frequency, extent and nature of contact with clients as well as providers. Further research, however, is needed to examine other strategies for improving continuity of care. In working with the coordinators, it became apparent that a general framework for helping coordinators to identify and resolve problems of continuity of care would be beneficial. In general, 23

31 due to high caseloads and low staffing it is clear that there is little time for reflection in the work of the case coordinator and a framework for assisting coordinators in thinking about continuity of care would be highly valuable. Such a framework, could build on the work of Reid et al and encourage coordinators in their interactions with clients to review whether 1) clients and providers have the information they need to manage care (informational continuity); 2) clients and providers are communicating and coordinating care (relational continuity) and 3) management structures are in place to assist with care (management continuity). Such a framework would encourage case coordinators to reflect on and attempt to resolve issues of continuity that fall within their practice. VII. References 1. Geron, S., & Chassler, D. (1994). Guidelines for case management practice across the long-term care continuum. The National Advisory Committee on Long-Term Care Case Management. 2. Lemire, A. M., & Austin, C. D. (1996). Care planning in home care: An exploratory study. Journal of Case Management, 5 (1), Hadjistavropoulos, H. D., Lawson, K. L., Peters, C., Asmundson, G. J. G., & Boisvert, J. A. (2002). Integrating admission and discharge services across the continuum of care: Evaluation results, challenges, and future directions. Healthcare Management Forum, 15, Diwan, S. (1999). Allocation of case management resources in long-term care: Predicting high use of case management time. The Gerontologist, 39, National Association of Social Workers. (1992). NASW Standards for Social Work Case Management. Washington, DC: Author. 6. Ontario Case Managers Association (2000). Provincial Standards and Guidelines for Case Management. Ontario Case Managers Association and Ontario Community Support Association: Newmarket, ON. 7. Case Management Society of America (2002). Standards of practice for case management. Little Rock, Arkansas: Author. 8. Raiff, N. R., & Shore, B. K. (1993). Advanced case management: New strategies for the nineties. Newbury Park, CA: Sage Publications, Inc. 9. Saskatchewan Home Care Program Assessment and Care Coordination Standards. (1988). Saskatchewan: Author. 24

32 10. Geron, S., & Chassler, D. (1994). Guidelines for case management practice across the long-term care continuum. The National Advisory Committee on Long-Term Care Case Management. 11. Quinn, J. L., Prybylo, M., & Pannone, P. (1999). Community care across the continuum. The Journal of Case Management, 1(4), Applebaum, R., & Mayberry, P. (1996). Long-term care case management: A look at alternative models. The Gerontologist, 36(5), Pepe, M. C., & Applebaum, R. A. (1996). Ohio s options for elder s alternative: Cutting corners or the cutting edge? Journal of Case Management, 5(1), Waszynski, C. M., Murakami, W., & Lewis, M. (2000). Community care management: Advanced practice nurses as care managers. The Journal of Case Management, 3(3), Gillis, Parsons, Neville, & Stein (2003). A practical approach to understanding risk of institutionalization in two Canadian cities: The Regina Risk Indicator Tool. Submitted to Healthcare Management Forum. 16. Folstein, M. F., Folstein, S. E., & McHugh, P. R. (1975). Mini-mental state. A practical method for grading the cognitive state of patients for the clinician. Journal of Psychiatric Research, 12, Tombaugh, T. N., & McIntyre, N. J. (1992). The Mini-Mental State Examination: A comprehensive review. Journal of the American Geriatrics Society, 40, Ware, J. Jr., Kosinski, M., Dewey, J., & Gandek, B. (2001). How to Score and Interpret Single-Item Health Status Measures: A Manual for Users of the SF-8(tm) Health Survey. Lincoln, RI: Quality Metric, Inc. 19. Koenig, H. G., Westlund, R. E., George, L. K., Hughes, D. C., Blazer, D. G., & Hybels, C. (1993). Abbreviating the Duke Social Support Index for use in chronically ill elderly individuals. Psychosomatics, 34, Hadjistavropoulos, H., Sagan, M., Bierlein, C., & Lawson, K. (2003). Development of a case management quality questionnaire. Journal of Case Management, 4(1), Crum, R. M., Anthony, J. C., Bassett, S. S, & Folstein, M. F. (1993). Population-based norms for the mini-mental state examination by age and educational level, JAMA, 18, Hughes, D. C., Blazer, D., Hybels, C. (1990). Duke Social Support Index (DSSI): A working paper (revised). Unpublished manuscript, Duke University Medical Center. 25

33 VIII. Appendices Appendix A Workload Tracking Form for Research Purposes Instructions: See details at bottom of page. Use circle, highlight or strikeout to clearly indicate selections. Please print names below. CLIENT LAST NAME: CLIENT (SWADD)#: Date of Activity YY-MM-DD Case Coordination Phase Int Asmt PlanDev PlanImp Mon RAsmt Dis Other Int Asmt PlanDev PlanImp Mon RAsmt Dis Other Int Asmt PlanDev PlanImp Mon RAsmt Dis Other Int Asmt PlanDev PlanImp Mon RAsmt Dis Other Int Asmt PlanDev PlanImp Mon RAsmt Dis Other Int Asmt PlanDev PlanImp Mon RAsmt Dis Other Int Asmt PlanDev PlanImp Mon RAsmt Dis Other Int Asmt PlanDev PlanImp Mon RAsmt Dis Other Int Asmt PlanDev PlanImp Mon RAsmt Dis Other Int: Intake Asmt: Assessment PlanDev: Plan Development PlanImp: Plan Implementation Mon: Monitoring RAsmt: Re-Assessment Dis: Discharge Other: Please specify under Comments Please see instruction sheet for detailed descriptions of categories and coding guidelines. When tracking sheet is full, please continue on a new sheet Coordinator: Type of Activity Contact With Time (minutes) In-Person Tcto TCfr Papr Res Trv CC Other In-Person Tcto TCfr Papr Res Trv CC Other In-Person Tcto TCfr Papr Res Trv CC Other In-Person Tcto TCfr Papr Res Trv CC Other In-Person Tcto TCfr Papr Res Trv CC Other In-Person Tcto TCfr Papr Res Trv CC Other In-Person Tcto TCfr Papr Res Trv CC Other In-Person Tcto TCfr Papr Res Trv CC Other In-Person Tcto TCfr Papr Res Trv CC Other In-Person: Face-to - face contact TCto: Coordinator initiated phone call TCfr: Phone call received, or responding to message from Papr: Paperwork, documentation, forms, letters, faxes, Res: Researching resources, reading files Trv: Travel CC: Case Conference NOTE: can select more than one if simultaneous (e.g., paperwork during a phone call) FIRST NAME: Comments (Optional) Use extra page if more space needed CL Fam SC SP-RHD SP-OTH MD PAC Other CW InfC OHS Dis Lit Psy MA PCH CL Fam SC SP-RHD SP-OTH MD PAC Other CW InfC OHS Dis Lit Psy MA PCH CL Fam SC SP-RHD SP-OTH MD PAC Other CW InfC OHS Dis Lit Psy MA PCH CL Fam SC SP-RHD SP-OTH MD PAC Other CW InfC OHS Dis Lit Psy MA PCH CL Fam SC SP-RHD SP-OTH MD PAC Other CW InfC OHS Dis Lit Psy MA PCH CL Fam SC SP-RHD SP-OTH MD PAC Other CW InfC OHS Dis Lit Psy MA PCH CL Fam SC SP-RHD SP-OTH MD PAC Other CW InfC OHS Dis Lit Psy MA PCH CL Fam SC SP-RHD SP-OTH MD PAC Other CW InfC OHS Dis Lit Psy MA PCH CL Fam SC SP-RHD SP-OTH MD PAC Other CW InfC OHS Dis Lit Psy MA PCH CL: Client Fam: Family Member SC: Own supervisor or colleague SP-RHD: Service provider, RHD SP-Oth: Service Provider, non-rhd MD: Doctor PAC: Program Access Committee Other: Please specify under Comments NOTE: can select more than one if simultaneous (e.g., met with client and family member together, met with client and service provider together) Record minutes of activity, rounded to the nearest 5 or 0. Activities less than 5 minutes are rounded up to 5. Examples - 2 minutes is rounded up to 5 minutes - 21 minutes rounds down to 20 minutes - 23 minutes rounds up to 25 minutes - 27 minutes rounds down to 25 minutes - 28 minutes rounds up to 30 minutes Include any comments relevant to the time required for this activity. Circle the complex circumstance code(s) if applicable. CW: Code White InfC: Infection Control OHS: Occ. Health and Safety issue Dis: Disagreement with care plan Lit: Litigation Psy: Psychiatric MA: Multi-agency PCH: Personal Care Home 26

34 Appendix B Case Coordination Guidelines Community Case Coordination Guidelines October 15,