Transcript Managing Continuity of Care Through Case Coordination

Managing Continuity of Care
Through Case Coordination
Developing and Evaluating
Guidelines for Case Coordination
Regina Qu’Appelle Health Region
& University of Regina
Committee Members
Principal Investigators
Dr. Heather Hadjistavropoulos
Sue Neville
Project Manager
Cecily Bierlein
Team Members
Mark Sagan
Dawn McNeil
Gretta Lynn Ell
Carolyn Bremner
Sharon Garratt
Thea Jacobs
Linda Wacker
Research Assistants
Allisson Quine
Michelle Bourgault
Tandy White
Project Funding
Canadian Health Services Research
Foundation ($100,000)
 Innovation and Science Fund,
Saskatchewan Economic and
Cooperative Development ($100,000)
 Regina Qu’Appelle Health Region
and University of Regina (services inkind)

Why did we complete this study?

Previous study found that stakeholders did not
know what to expect from case coordinators in
terms of frequency and nature of services
 Case coordination was perceived to differ
considerably amongst coordinators, and also was
perceived to be inconsistently linked to the level
of need of the client
 No other data was found in a literature review
specifying time and need based case coordination
guidelines
Objectives
Systematically develop guidelines for
case coordination (nature and frequency
of service) that are linked to the client’s
level of risk for requiring placement in
an institution or need for extended
health care services
 Guidelines will vary for clients at
different levels of risk

Objectives (continued)
The second major objective is to
evaluate the guidelines from the
perspective of various stakeholders
 This will be done through focus
groups with clients/family members,
coordinators, providers and decision
makers

Method

From October 2001 to December 2002, data was
collected on 234 clients over age 65 who were
assigned to case coordinators

Clients were assessed for mental status, physical
and emotional health status, social supports and
other risk indicators through standardized
measures

Following six months of case coordination,
clients were reassessed for changes in their
condition, and satisfaction with case coordination
services
Method (continued)

Case coordinators tracked workload on an ongoing
basis for clients enrolled in the study (e.g., time
spent on needs assessment, plan development,
etc.)

Home Care (HC) and Long Term Care (LTC)
databases were used to track the nature and
frequency of services secured for clients (e.g.,
Homemaking, Day Program)
Data Analysis Plan
1)
Better understand clients who receive
case coordination services and how they
change over time
2)
Explore correlates of case management
time to determine which variables (e.g.,
risk, physical function, cognitive status,
social support) are correlated with case
management and therefore can be used
to predict case management time
Data Analysis Plan (continued)

Use data to develop case management
guidelines – how much time should case
coordinators spend with low vs high
need clients?

Use focus groups to evaluate guidelines
Overview of Clients, Service
Use and Satisfaction
Status of Participants At Six
Months (n = 234)
Deceased
5.1%
Active at Six
Months
71.4%
Supports
Improved
3.8%
Early
Discharge
28.6%
ImprovedServices Not
Needed
11.5%
Other
3.0%
Left District
2.6%
Needs
Exceeded
Resources
Available
1.7%
Refused
Further
Services
0.9%
Demographics
Sex
Marital Status
Sep./Div.
5%
Single
6%
Men
36%
Women
66%
Married
40%
Widowed
48%
Average age = 80 years (ranging from age 65 to 101)
Living Arrangement
Time One
3%
Time Two
2% 2%
1%
8%
Own Home
10%
Family/Friend's Home
Personal Care Home
86%
Other
Long Term Care
11%
77%
Social Support
No significant - 2%
16% unstable/no significant support
Unstable/short term - 14%
Stable, available - 35%
Stable, limited - 49%
84% stable support
Stable, Available - lives in the
same home; emotionally and
physically able to provide
support
Stable, Limited - does not live
in same home; emotionally
and physically able to provide
support
Unstable - emotionally and
physically unable to provide
support
Categories of Risk of Institutionalization
60
Majority in the low and
some risk categories
50
40
Time One
Time Two
30
20
10
0
Minimum
Low
Some
At Risk
High
Change in Risk of Institutionalization

RRIT Category
Decreased
 RRIT Category
Stayed Same
 RRIT Category
Increased
25%
Increased
21%
Decreased
25%
54%
21%
No Change
54%
Service Use: Home Care
% of Clients Who Used Service
72
Occupational Therapy
Homemaking
47
38
Nursing
15
Physical Therapy
Meals on Wheels
7
Social Work
6
Service Use: Home Care Over 6 Months
10
9
8
H
o
u
r
s
7.2
7.1
7.7
8.8
8.8
8.3
7
6
Professional Services
Support Services
5
4
3.1
4.7
3
2
3.6
4.2
4.5
4
5
4.1
3.7
2.5
1
0
(Average)
0
1
2
3
Months
6
Service Use By Risk Category
Average
Service Use
20
18
16
14
12
10
8
6
4
2
0
Mininmal/Low
Some
At/High
0
1
2
3
Months
4
5
6
Measures Over the Six Month Period
MMSE
Mean at
Time One
Mean at
Time Two
24.93
24.70
Risk of Institutionalization 14.71
13.99 *
SF-8 Physical Health
34.42
38.87 **
47.01
51.10 **
48.12
47.35 *
Population Norm of 45.46 to 47.41
SF-8 Mental Health
Population Norm of 51.98 to 52.33
Duke Social Support
* p < .05
** p < .01
Client Satisfaction

94% satisfied with coordination at the first
interview, and 91% satisfied with coordination at
the second interview.
 Most clients felt like services met their needs,
and felt like the coordinator was caring.
 Some clients desired more contact from their
coordinator, needed delays explained, and
desired the coordinator to review their needs
more frequently.
Measuring
Case Coordination Activity
Case Coordination Activity
Tracking Form Overview

Date of Activity
 Case Coordination Phase
– Intake, Assessment, Plan Development, Plan
Implementation, Monitoring, Reassessment, Discharge

Type of Activity
– In-Person, Telephone Call To, Telephone Call From,
Paperwork, Research, Travel, Case Conference, Other

Contact With
– Client, Family, Supervisor/Colleague, Service Provider
(District and Other), MD, Program Access Committee, Other

Time (minutes)
 Comments and Complex Circumstances
(optional)
CLIENT LAST NAME: Longstocking
FIRST NAME: Pippi
Ease
of
Coordinator: Mr.
Nelson
CLIENT #: 7654321
Date of
Activity
Case Coordination
Phase
Type of Activity
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
In-Person
TCfr Papr
Trv CC
In-Person
TCfr Papr
Trv CC
In-Person
TCfr Papr
Trv CC
In-Person
TCfr Papr
Trv CC
Contact With
YY-MM-DD
01-07-31
01-07-31
01-08-01
“
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
TCto
Res
Other
TCto
Res
Other
TCto
Res
Other
TCto
Res
Other
In-Person: Face-toface contact
TCto: Coordinator
initiated phone call
TCfr: Phone call
received, or responding
to message from
Papr: Paperwork,
documentation, forms,
letters, faxes, e-mail
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.)
CL
Fam
SC
SP-RHD SP-OTH
MD PAC Other
CL
Fam
SC
SP-RHD SP-OTH
MD PAC Other
CL
Fam
SC
SP-RHD SP-OTH
MD PAC Other
CL
Fam
SC
SP-RHD SP-OTH
MD PAC Other
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
use - no code
Time
sheets neededComments
(minutes)
(Optional)
Tracking
of
comments
Use extra page if more space needed
95 and special
circumstances
CW InfC OHS Dis Lit Psy MA PCH
30
To and from
CW InfC OHS Dis Lit Psy MA PCH
25
Resistant infection
CW InfC OHS Dis Lit Psy MA PCH
20
Time recorded in
(rounded)
CWminutes
InfC OHS Dis
Lit Psy MA
Record minutes of
activity, rounded to the
nearest “5” or “0.”
Activities less than 5
minutes are rounded up
to 5.
PCH
Include any comments
relevant to the time
required for this
activity.
Circle the complex
circumstance code(s)
if applicable.
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
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
Straightforward instructions and
definitions on the bottom of each page
Individual Case Record Example
Subject #
200101
200101
200101
200101
200101
200101
200101
200101
200101
200101
200101
200101
200101
200101
200101
200101
200101
200101
200101
Date
25-Sep-01
25-Sep-01
26-Sep-01
26-Sep-01
26-Sep-01
26-Sep-01
26-Sep-01
26-Sep-01
26-Sep-01
26-Sep-01
26-Sep-01
04-Oct-01
12-Oct-01
31-Oct-01
31-Oct-01
14-Dec-01
15-Dec-01
21-Dec-01
21-Dec-01
Phase
Activity
Intake
TCfr
Intake
TCto
Asmt
TCto
Asmt
In-Person
Asmt
Trv
Asmt
Papr
PlanDev In-Person
PlanImp TCto
PlanImp In-Person
PlanImp TCto
PlanImp TCto
PlanImp Papr
Monitoring Papr
Monitoring Papr
Monitoring Papr
Monitoring Papr
Monitoring Papr
Monitoring TCfr
Monitoring Papr
Contact With
Time
Client
20
Client
5
Family
5
Client and Family
90
Client and Family
45
SP-RHD (serv provider, RHD)
60
Client and Family
30
SC (supervsr, colleague)
10
SC (supervsr, colleague)
10
Client
5
SC (supervsr, colleague)
5
SP-RHD (serv provider, RHD)
10
SP-RHD (serv provider, RHD)
5
SP-RHD (serv provider, RHD)
5
SP-RHD (serv provider, RHD)
5
SP-RHD (serv provider, RHD)
10
SP-RHD (serv provider, RHD)
5
SP-RHD (serv provider, RHD)
5
SP-RHD (serv provider, RHD)
5
Collection of Case Coordination
Activity Data

Case coordination data collection began on
Sept 24, 2001, with the first set of data (six
months from coordinator start date) completed
on March 25, 2003

Case coordination data collection was
completed on the last client on Nov 25, 2002

167 of 234 clients (71.4%) completed six
months of case coordination, with 67 clients
being discharged in under six months
Case Coordination Activity
Tracked During the Study

72,325 minutes (1,205.4 hours) of activity
was tracked for 234 clients in 4,310
activity tracking entries
– Mean = 309.1 minutes (5.15 hrs) per client,
SD = 214.5, Range of 35 to 1,450 minutes
(24.2 hrs) with Median of 245 minutes (4.1
hrs)
– Mean = 18.4 entries per client, SD = 15.0,
range of 4 to 109 entries per client
– Mean = 16.8 minutes per activity, SD = 17.7,
range of 5 minutes to 120 minutes
Total Case Coordination Hours
Per Client (Months 0 to 6)
71% of the clients received
between 2 and 6 hours of case
coordination over six months
(including intake time)
45
41.5
40
35
29.1
30
Percent of
25
Clients
(n = 234) 20
26% of the clients accounted
for 49% of the total case
coordination time
15
12.0
10
6.4
24.0-25.9
22.0 - 23.9
20.0 - 21.9
18 - 19.9
16.0 - 17.9
14.0 - 15.9
12.0 - 13.9
10.0 - 11.9
8.0 - 9.9
6.0 - 7.9
4.0 - 5.9
Total
Hours
2.1 1.7 0.9 0.4 0.9 0.4 0.4 0.4
2.0 - 3.9
0
0 - 1.9
5 3.8
Total Coordination Hours by
Month (n = 234)
Month 6
Month 5
Month 4
Month 3
Month 2
Month 1
64%of the total case
coordination activity took
place in the first month
Month 0
350
300
250
200
150
100
50
0
Average Coordination Time Per
Client by Month (n = 234)
Minutes
240
195
180
120
60
72
20
233
100%
129
55%
52
49
39
97
42%
75
32%
59
25%
54
43
18%
0
Month Month Month Month Month Month Month
0
1
2
3
4
5
6
Percent of Clients Receiving Coordination Service(s)
Total Coordination Time by Type
of Activity, Months 0-6 (n = 234)
387
400
361
1%
177
200
120
115
100
32%
24%
30%
10%
7
4
1
as
e
C
er
O
th
fe
re
nc
e
el
C
on
Tr
av
ch
ar
es
e
R
w
or
k
ap
er
P
Fr
om
TC
To
TC
Pe
r
so
n
0
In
-
Hours
300
Mean of Total Coordination Time
(Months 0-6) by RRIT Level, Time 1
10
Hours
8
8.3
6
4
6.8
5.6
4.6
4.2
2
0
Minimal
Risk (0-7)
(n = 6)
Low Risk
(8-14)
Some Risk
(15-20)
(n = 118)
(n = 83)
At Risk (2125)
High Risk
(26+)
(n = 22)
(n = 5)
Average Case Coordination Time
Per Client by Month by Risk Level
4
3
Minimal/Low (0-14), n =124
Hours
Some Risk (15-20), n = 83
2
At/High Risk (21+), n = 27
1
0
Month 0 Month 1 Month 2 Month 3 Month 4 Month 5 Month 6
Note: Outliers adjusted, n constant within each group with months with “0”
time included in calculation of the group mean
Average Case Coordination Time by
Phase by Risk Level, Months 0-6
Minimal/Low (0-14), n = 124
Some Risk (15-20), n = 83
At/High Risk (21+), n = 27
1
er
O
th
e
D
isc
ha
rg
s
ea
ss
es
R
to
r
on
i
M
ev
D
Im
p
Pl
an
ss
e
A
Pl
an
ss
m
en
t
ta
ke
0
In
Hours
2
Average Case Coordination Time by
Contact With by Risk Level, Months 0-6
3
Minimal/Low (0-14), n = 124
Some Risk (15-20), n = 83
2
Hours
Higher Risk (21+), n = 27
1
th
er
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o
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&
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ith
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Fa
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ily
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m
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Correlations with Total Case
Coordination Time (Months 0-6)
RRIT Score (Time 1)
MMSE Score (Time 1)
.29**
-.21**
Home Care Service Units, All
.32**
Home Care Professional Services
.27**
Home Care Support Services
.26*
# of Hospital Admissions
.36**
(62 clients with one or more admissions in months 0-6)
Days in Hospital
.44**
ER Visits
.22**
(68 clients with one or more ER visits in months 0-6)
* p < .05
** p < .01
Guideline Development
How can guidelines help?







Foster realistic expectations
Improve communication with clients
Improve time management among
coordinators and accountability
Increase consistency in service
Improve matching of service with needs
Allow for evaluation of case coordination
(e.g., are services adequate, equitable, and
consistent?)
Allow for resource planning
Guideline Development Strategy

Correlations/ANOVAs of specific client
variables with case management time
were analyzed – RRIT best variable
 The population was divided into client
subgroups (low/some/high) for guideline
development
 Expert panel reviewed data and wrote the
guidelines
Guidelines
At/High RRIT
Total Hours:
Assess
Plan Dev
Median Time over 6 months
6 hrs
140 min
90 min
90 min
70 min
80 min
Range of Time over 6 months
4-13 hrs
100-230
40-250
30-180
60-160
30-140





Plan Imp
Monitoring
Reasmnt
Case coordinators should use the times listed above as a measure of suggested case coordination time.
Service providers (day support/respite/home care/PCH operator) will send written updates to coordinators at
one year, or at specified trigger points from the coordinator’s assessment date for supportive, long term
community clients.
Case coordinators will complete a monitoring review at 3 months, annually, and at specified trigger points for
supportive, long term community clients.
Full Reassessments will be completed annually or when any trigger for case coordination monitoring occurs
for which the coordinator does not have adequate information to proceed without an in-person assessment.
Cases with extreme (outside guideline amounts) coordination time after six months should be reviewed by the
coordinator with the supervisor.
Assessment
Learning about the client and gathering
information about her or his needs.
Low:
100 minutes
(60 - 150)
Some: 120 minutes
(80 - 160)
High:
(100 - 230)
140 minutes
Plan Development
Deciding what services would meet the
client’s needs.
Low:
50 minutes
(20 - 90)
Some: 70 minutes
(30 - 150)
High:
(40 - 250)
90 minutes
*based on a six month time period
Plan Implementation
Setting up and coordinating services.
Low:
40 minutes
Some: 70 minutes
High:
90 minutes
*based on a six month time period
(20 - 80)
(20 - 150)
(30 - 180)
Monitoring
Making sure services are meeting client’s
needs and services are being provided.
Low:
30 minutes
(10 - 100)
Some: 50 minutes
(20 - 140)
High:
(60 - 160)
70 minutes
*based on a six month time period
Reassessment
Re-evaluating client needs on an ongoing
basis or because of changes.
All Groups (low, some, high):
80 minutes
(30 - 140)
How often will the coordinator be
involved in a client’s care?

At the initial assessment
 Service Providers will give updates to the coordinator
at 3 months and annually.
 When the client experiences a significant change, the
coordinator will complete a service review or a
reassessment
 Full Reassessments are carried out on low RRIT
clients every 3 years, and Some/At/High RRIT clients
at 1 year intervals
Triggers
Indicators that a client may need more case
management time







Hospital or Emergency Room Visit
Change in Client’s Physical Status
Change in Client’s Emotional/Cognitive Status
Change in Client Behaviour
Change in Social Support
Change in Service Use
Change in RRIT
Focus Groups
Focus Groups: Positives vs
Negatives
Positive
Objective Data
Service Reviews
Efficiency
Education and Training
Consistency
Opportunity for Supervision
Negative
Increased Workload
Can’t Quantify Case Mangmt.
More Client Focus
Actual Practice
More Reviews
Not Helpful to Case Managers
Focus Groups: Barriers to
Implementation





Fear of rigid application
Disconnection between coordinators and
service providers
Staff buy-in
Increased paperwork
High caseload size
Data Usage

Increase awareness of current case management
practice
 Estimate workload
 Identify outliers with too much or too little case
management
 Train new workers
 Make a client brochure
 Develop information sheet for providers that
describes case coordination and when to contact the
case coordinator
Data Usage


Identify clients who case manager may wish to
discuss with their manager
Method used by management to review random
client files on a yearly basis to make sure
coordination is fair and consistent
Piloting the Guidelines
Pilot in Progress
Piloting new tracking form
 Piloting service review forms
 Will complete structured interviews
at the end of June 2003 to determine
revisions and manageable amount to
track at any given time

Potential Future Directions

Implementation of Guidelines
– Use in Orientation and Training
– Use for Performance Development with
a Quality Tool
– Automation of the Tracking Form on a
Centralized Database
– Analyze specific outcomes after
implementation
Potential Future Directions

Gather Further Data on Months 6-12

Analyze Case Management Intensity
– Caseload Mix and Caseload Size
Acknowledgements






Thanks to the SWADD case coordinators who
tracked their time so diligently
Thanks to the clients who consented to be
interviewed
Thanks to the focus group participants
Thanks to the Regina Qu’Appelle Health Region
for its in-kind contributions
Thanks to the University of Regina and our
research assistants
Thanks to the research committee who spent
countless hours with this project
Questions
For further information contact:
Dr. H. Hadjistavropoulos
Associate Professor
Dept. of Psychology
U of R
Regina,SK
S4S 0A2
585-5133
[email protected]
Cecily Bierlein
Research Associate
4211 Albert St.
Regina, SK
S4S 3R6
766-7175
cecily.bierlein@
rqhealth.ca
http://uregina.ca/~case_coordination.html