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Managing Continuity of Care Managing Continuity of Care Through Case CoordinationThrough Case Coordination
Developing and Evaluating Guidelines for Case Coordination
Regina Qu’Appelle Health Region
& University of Regina
Committee MembersCommittee 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
Project FundingProject 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)
Why did we complete this study?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
ObjectivesObjectives
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)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
MethodMethod
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)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 PlanData 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)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 Overview of Clients, Service Use and SatisfactionUse and Satisfaction
Status of Participants At Six Status of Participants At Six Months (n = 234)Months (n = 234)
Left District2.6%
Supports Improved
3.8%
Deceased5.1%
Active at Six Months71.4%
Early Discharge
28.6%
Improved-Services Not
Needed11.5%
Refused Further Services
0.9%Other3.0%
Needs Exceeded Resources Available
1.7%
DemographicsDemographics
Men36%
Women66%
Sep./Div.5%
Single6%
Married40%
Widowed48%
Sex Marital Status
Average age = 80 years (ranging from age 65 to 101)
Living ArrangementLiving Arrangement
1%3%
10%
86%
Own Home
Family/Friend's Home
Personal Care Home
Other
Long Term Care
Time One
2%2%8%
11%
77%
Time Two
Social SupportSocial Support
Stable, available - 35%
Stable, limited - 49%
Unstable/short term - 14%
No significant - 2%
Unstable - emotionally and physically unable to provide support
Stable, Available - lives in the same home; emotionally and physically able to provide supportStable, Limited - does not live in same home; emotionally and physically able to provide support
84% stable support
16% unstable/no significant support
Categories of Risk of InstitutionalizationCategories of Risk of Institutionalization
0
10
20
30
40
50
60
Minimum Low Some At Risk High
Time OneTime Two
Majority in the low and some risk categories
Change in Risk of InstitutionalizationChange in Risk of Institutionalization
RRIT Category Decreased 25%
RRIT Category Stayed Same 54%
RRIT Category Increased 21%
No Change54%
De-creased
25%
Increased21%
Service Use: Home CareService Use: Home Care
6
7
15
38
47
72Occupational Therapy
Homemaking
Nursing
Physical Therapy
Meals on Wheels
Social Work
% of Clients Who Used Service
Service Use: Home Care Over 6 MonthsService Use: Home Care Over 6 Months
3.1 4.7
3.74.2 4.5
4.13.6
2.5
7.2 7.17.7 8.8 8.8
8.3
0
1
2
3
4
5
6
7
8
9
10
0 1 2 3 4 5 6
Professional ServicesSupport Services
H
o
u
r
s
Months
(Average)
Service Use By Risk CategoryService Use By Risk Category
02468
101214161820
0 1 2 3 4 5 6
Mininmal/LowSome
At/High
Months
AverageService Use
Measures Over the Six Month PeriodMeasures Over the Six Month PeriodMean at Mean at
Time One Time 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
Client SatisfactionClient 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 Measuring Case Coordination ActivityCase Coordination Activity
Case Coordination Activity Case Coordination Activity Tracking Form OverviewTracking 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
CLIENT #: 7654321 Coordinator: Mr. Nelson
Date ofActivityYY-MM-DD
Case CoordinationPhase
Type of Activity Contact With Time(minutes)
Comments
(Optional)Use extra page if more space needed
01-07-31 Int Asmt PlanDevPlanImp Mon RAsmtDis Other
In-Person TCtoTCfr Papr ResTrv CC Other
CL Fam SCSP-RHD SP-OTHMD PAC Other
95
CW InfC OHS Dis Lit Psy MA PCH
01-07-31 Int Asmt PlanDevPlanImp Mon RAsmtDis Other
In-Person TCtoTCfr Papr ResTrv CC Other
CL Fam SCSP-RHD SP-OTHMD PAC Other
30
CW InfC OHS Dis Lit Psy MA PCH
01-08-01 Int Asmt PlanDevPlanImp Mon RAsmt
Dis Other
In-Person TCtoTCfr Papr Res
Trv CC Other
CL Fam SCSP-RHD SP-OTH
MD PAC Other
25
CW InfC OHS Dis Lit Psy MA PCH
“ Int Asmt PlanDevPlanImp Mon RAsmt
Dis Other
In-Person TCtoTCfr Papr Res
Trv CC Other
CL Fam SCSP-RHD SP-OTH
MD PAC Other
20
CW InfC OHS Dis Lit Psy MA PCH
Int: IntakeAsmt: AssessmentPlanDev: Plan DevelopmentPlanImp: Plan
ImplementationMon: MonitoringRAsmt: Re-AssessmentDis: DischargeOther: Please specify
under “Comments”
Please see instructionsheet for detaileddescriptions of categoriesand coding guidelines.
When tracking sheet isfull, please continue on anew sheet
In-Person: Face-to-face contactTCto: Coordinatorinitiated phone callTCfr: Phone callreceived, or respondingto message fromPapr: Paperwork,documentation, forms,letters, faxes, e-mailRes: Researchingresources, reading filesTrv: TravelCC: Case Conference
NOTE: can select morethan one if simultaneous(e.g., paperwork duringa phone call.)
CL: ClientFam: Family MemberSC: Own supervisor orcolleagueSP-RHD: Serviceprovider, RHDSP-Oth: ServiceProvider, non-RHDMD: DoctorPAC: Program AccessCommitteeOther: Please specifyunder “Comments”
NOTE: can select morethan one if simultaneous(e.g., met with client andfamily member together,met with client andservice provider together)
Record minutes ofactivity, rounded to thenearest “5” or “0.”Activities less than 5minutes are rounded upto 5.
Examples- 2 minutes is roundedup to 5 minutes- 21 minutes roundsdown to 20 minutes- 23 minutes rounds upto 25 minutes- 27 minutes roundsdown to 25 minutes- 28 minutes rounds upto 30 minutes
Include any commentsrelevant to the timerequired for thisactivity.
Circle the complexcircumstance code(s)if applicable.
CW: Code WhiteInfC: InfectionControlOHS: Occ. Healthand Safety issueDis: Disagreementwith care planLit: LitigationPsy: PsychiatricMA: Multi-agencyPCH: Personal CareHome
Resistant infection
To and from
Ease of use - no code sheets needed
Tracking of comments and special circumstances
Straightforward instructions and definitions on the bottom of each page
Time recorded in minutes (rounded)
Individual Case Record ExampleIndividual Case Record ExampleSubject # Date Phase Activity Contact With Time
200101 25-Sep-01 Intake TCfr Client 20200101 25-Sep-01 Intake TCto Client 5200101 26-Sep-01 Asmt TCto Family 5200101 26-Sep-01 Asmt In-Person Client and Family 90200101 26-Sep-01 Asmt Trv Client and Family 45200101 26-Sep-01 Asmt Papr SP-RHD (serv provider, RHD) 60200101 26-Sep-01 PlanDev In-Person Client and Family 30200101 26-Sep-01 PlanImp TCto SC (supervsr, colleague) 10200101 26-Sep-01 PlanImp In-Person SC (supervsr, colleague) 10200101 26-Sep-01 PlanImp TCto Client 5200101 26-Sep-01 PlanImp TCto SC (supervsr, colleague) 5200101 04-Oct-01 PlanImp Papr SP-RHD (serv provider, RHD) 10200101 12-Oct-01 Monitoring Papr SP-RHD (serv provider, RHD) 5200101 31-Oct-01 Monitoring Papr SP-RHD (serv provider, RHD) 5200101 31-Oct-01 Monitoring Papr SP-RHD (serv provider, RHD) 5200101 14-Dec-01 Monitoring Papr SP-RHD (serv provider, RHD) 10200101 15-Dec-01 Monitoring Papr SP-RHD (serv provider, RHD) 5200101 21-Dec-01 Monitoring TCfr SP-RHD (serv provider, RHD) 5200101 21-Dec-01 Monitoring Papr SP-RHD (serv provider, RHD) 5
Collection of Case Coordination Collection of Case Coordination Activity Data 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 Case Coordination Activity Tracked During the Study 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 Total Case Coordination Hours Per Client (Months 0 to 6)Per Client (Months 0 to 6)
3.8
41.5
29.1
12.0
6.42.1 1.7 0.9 0.4 0.9 0.4 0.4 0.4
0
5
10
15
20
25
30
35
40
45
Percent of Clients
(n = 234)
0 -
1.9
2.0
- 3.
9
4.0
- 5.
9
6.0
- 7.
9
8.0
- 9.
9
10.0
- 1
1.9
12.0
- 1
3.9
14.0
- 1
5.9
16.0
- 1
7.9
18 -
19.
9
20.0
- 2
1.9
22.0
- 2
3.9
24.0
-25.
9
Total Hours
26% of the clients accounted for 49% of the total case
coordination time
71% of the clients received between 2 and 6 hours of case coordination over six months
(including intake time)
Total Coordination Hours by Total Coordination Hours by Month (n = 234)Month (n = 234)
0
50
100
150
200
250
300
350M
onth
0
Mon
th 1
Mon
th 2
Mon
th 3
Mon
th 4
Mon
th 5
Mon
th 6
64%of the total case coordination activity took place in the first month
Average Coordination Time Per Average Coordination Time Per Client by Month (n = 234)Client by Month (n = 234)
233 129 4397 75 59
195
72
394952 5420
0
60
120
180
240
Month0
Month1
Month2
Month3
Month4
Month5
Month6
Minutes
100% 55% 42% 32% 25% 18%
Percent of Clients Receiving Coordination Service(s)
Total Coordination Time by Total Coordination Time by Type of Activity, Months 0-6 (n Type of Activity, Months 0-6 (n
= 234)= 234)387
177
115
361
7
120
4 10
100
200
300
400
Ho
urs
10%10%32%32% 24%24% 30%30%
1%1%
Mean of Total Coordination TimeMean of Total Coordination Time(Months 0-6) by RRIT Level, Time 1(Months 0-6) by RRIT Level, Time 1
4.6 4.2
5.6
6.8
8.3
0
2
4
6
8
10
MinimalRisk (0-7)
Low Risk (8-14)
Some Risk(15-20)
At Risk (21-25)
High Risk(26+)
Hou
rs
(n = 6) (n = 83)(n = 118) (n = 5)(n = 22)
Average Case Coordination Time Average Case Coordination Time Per Client by Month by Risk LevelPer Client by Month by Risk Level
0
1
2
3
4
Month 0 Month 1 Month 2 Month 3 Month 4 Month 5 Month 6
Ho
urs
Minimal/Low (0-14), n =124
Some Risk (15-20), n = 83
At/High Risk (21+), n = 27
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 Average Case Coordination Time by Phase by Risk Level, Months 0-6Phase by Risk Level, Months 0-6
0
1
2
Hou
rs
Minimal/Low (0-14), n = 124Some Risk (15-20), n = 83At/High Risk (21+), n = 27
Average Case Coordination Time by Average Case Coordination Time by Contact With by Risk Level, Months 0-6Contact With by Risk Level, Months 0-6
0
1
2
3
Hou
rs
Minimal/Low (0-14), n = 124
Some Risk (15-20), n = 83
Higher Risk (21+), n = 27
Correlations with Total Case Correlations with Total Case Coordination Time (Months 0-6)Coordination Time (Months 0-6)
RRIT Score (Time 1) .29**
MMSE Score (Time 1) -.21**
Home Care Service Units, All .32**
Home Care Professional Services .27**
Home Care Support Services .26*
# of Hospital Admissions(62 clients with one or more admissions in months 0-6)
.36**
Days in Hospital .44**
ER Visits(68 clients with one or more ER visits in months 0-6)
.22**
* p < .05 ** p < .01
Guideline DevelopmentGuideline Development
How can guidelines help?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 StrategyGuideline 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
At/High RRIT Total Hours: Assess Plan Dev Plan Imp Monitoring
ReasmntMedian 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.
GuidelinesGuidelines
AssessmentAssessment
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)
Plan DevelopmentPlan 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
Plan ImplementationPlan 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
MonitoringMonitoring
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
Reassessment 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 How often will the coordinator be involved in a client’s care?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
TriggersTriggers
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 GroupsFocus Groups
Focus Groups: Positives vs Focus Groups: Positives vs NegativesNegatives
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
Focus Groups: Barriers to Focus Groups: Barriers to ImplementationImplementation
Fear of rigid application Disconnection between coordinators and
service providers Staff buy-in Increased paperwork High caseload size
Data UsageData 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 UsageData 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 GuidelinesPiloting the Guidelines
Pilot in ProgressPilot in Progress
Piloting new tracking formPiloting service review formsWill complete structured interviews
at the end of June 2003 to determine revisions and manageable amount to track at any given time
Potential Future DirectionsPotential 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 DirectionsPotential Future Directions
Gather Further Data on Months 6-12
Analyze Case Management Intensity– Caseload Mix and Caseload Size
AcknowledgementsAcknowledgements 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
QuestionsQuestions
For further information contact:For further information contact:
Dr. H. Hadjistavropoulos
Associate Professor
Dept. of Psychology
U of R
Regina,SK
S4S 0A2
585-5133
Cecily Bierlein
Research Associate
4211 Albert St.
Regina, SK
S4S 3R6
766-7175
cecily.bierlein@
rqhealth.ca
http://uregina.ca/~case_coordination.html
