Managing Continuity of Care Through Case Coordination

1. Managing Continuity of Care Through Case Coordination Developing and Evaluating Guidelines for Case Coordination Regina Qu’Appelle Health Region & University of Regina

2. Committee Members Principal Investigators Project Manager Dr. Heather Hadjistavropoulos Cecily Bierlein Sue Neville Team Members Mark Sagan Sharon Garratt Dawn McNeil Thea Jacobs Gretta Lynn Ell Linda Wacker Carolyn Bremner Research Assistants Allisson Quine Tandy White Michelle Bourgault

3. 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 in- kind)

4. 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

5. 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

6. 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

7. 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

8. 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)

9. Data Analysis Plan • Better understand clients who receive case coordination services and how they change over time • 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

10. 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

11. Overview of Clients, Service Use and Satisfaction

12. Status of Participants At Six Months (n = 234)

13. Demographics Sex Marital Status Average age =80 years (ranging from age 65 to 101)

14. Living Arrangement Time One Time Two

15. 16% unstable/no significant support 84% stable support Social Support No significant - 2% Unstable/short term - 14% 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 Stable, available - 35% Stable, limited - 49% Unstable - emotionally and physically unable to provide support

16. Majority in the low and some risk categories Categories of Risk of Institutionalization

17. Change in Risk of Institutionalization • RRIT Category Decreased 25% • RRIT Category Stayed Same 54% • RRIT Category Increased 21%

18. Service Use: Home Care % of Clients Who Used Service

19. Service Use: Home Care Over 6 Months H o u r s (Average) Months

20. Service Use By Risk Category Average Service Use Months

21. Measures Over the Six Month Period Mean at Mean at Time OneTime Two MMSE 24.93 24.70 Risk of Institutionalization 14.71 13.99 * SF-8 Physical Health 34.42 38.87 ** Population Norm of 45.46 to 47.41 SF-8 Mental Health 47.01 51.10 ** Population Norm of 51.98 to 52.33 Duke Social Support 48.12 47.35 * * p < .05** p < .01

22. 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 reviewtheir needs more frequently.

23. Measuring Case Coordination Activity

24. 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)

25. Ease of use - no code sheets needed Tracking of comments and special circumstances Time recorded in minutes (rounded) Straightforward instructions and definitions on the bottom of each page

26. Individual Case Record Example

27. 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

28. 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

29. 71% of the clients received between 2 and 6 hours of case coordination over six months (including intake time) 26% of the clients accounted for 49% of the total case coordination time Total Case Coordination Hours Per Client (Months 0 to 6) Total Hours

30. 64%of the total case coordination activity took place in the first month Total Coordination Hours by Month (n = 234)

31. 100% 55% 42% 32% 25% 18% Percent of Clients Receiving Coordination Service(s) Average Coordination Time Per Client by Month (n = 234)

32. 1% 10% 32% 24% 30% Total Coordination Time by Type of Activity, Months 0-6 (n = 234)

33. Mean of Total Coordination Time(Months 0-6) by RRIT Level, Time 1 (n = 6) (n = 118) (n = 83) (n = 22) (n = 5)

34. Average Case Coordination Time Per Client by Month by Risk Level Note: Outliers adjusted, n constant within each group with months with “0” time included in calculation of the group mean

35. Average Case Coordination Time by Phase by Risk Level, Months 0-6

36. Average Case Coordination Time by Contact With by Risk Level, Months 0-6

37. Correlations with Total Case Coordination Time (Months 0-6)

38. Guideline Development

39. 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

40. 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

41. Guidelines At/High RRIT Total Hours: Assess Plan Dev Plan Imp Monitoring Reasmnt 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 • 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.

42. Assessment Learning about the client and gathering information about her or his needs. Low: 100 minutes (60 - 150) Some: 120 minutes (80 - 160) High: 140 minutes (100 - 230)

43. Plan Development Deciding what services would meet the client’s needs. Low: 50 minutes (20 - 90) Some: 70 minutes (30 - 150) High: 90 minutes (40 - 250) *based on a six month time period

44. Plan Implementation Setting up and coordinating services. Low: 40 minutes (20 - 80) Some: 70 minutes (20 - 150) High: 90 minutes (30 - 180) *based on a six month time period

45. 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: 70 minutes (60 - 160) *based on a six month time period

46. Reassessment Re-evaluating client needs on an ongoing basis or because of changes. All Groups (low, some, high): 80 minutes (30 - 140)

47. 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

48. 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

49. Focus Groups

50. Focus Groups: Positives vs Negatives Positive Negative Objective Data Increased Workload Service Reviews Can’t Quantify Case Mangmt. Efficiency More Client Focus Education and Training Actual Practice Consistency More Reviews Opportunity for Supervision Not Helpful to Case Managers