A glimpse inside the incubator: Creating new CM outcomes tool
Goal is usefulness across populations
EXECUTIVE SUMMARY
Case management work increasingly is being measured, but the big issue is finding tools for effective measurement of CM outcomes.
- Hospitalization rates are an indirect way to measure a negative outcome.
- A measurement tool should address the case management consumer’s progress from using professional support to less restrictive, more natural support.
- One tool under development measures domains and living situations, activities of daily living, financial, educational, vocational, and other factors.
Case management (CM) work increasingly is under measurement. Often, the tools used to indicate CM outcomes look at healthcare utilization and costs. But are these really the best ways to measure outcomes? That’s the question researchers and a mobile case management services company asked before embarking on a mission to create a better case management measurement tool.
“We wanted something that was really congruent with and a measure of how well we were fulfilling our mission of helping people improve self-sufficiency and improve community integration,” says Jeffrey Marks, MA, director of clinical services, Service Access and Management, Inc. of Reading, PA.
Using hospitalization rates as a measurement is not ideal because it indirectly measures a negative outcome, Marks says.
“Hospitalization can represent the failure of the consumer to be independent and self-sufficient,” he explains. “We were looking for something more direct, more sensitive.”
The new measurement would be evidence-based and more directly applicable to case management service planning. It would be useful in measuring case management across all populations, Marks says.
“It was our desire to find an effectiveness tool with some sort of analysis behind it,” says Lori Hartman, MA, deputy director of operations at SAM.
SAM needed a partner to help develop the new tool. Through connections on an advisory board, two researchers from Clarion University in Clarion, PA, became collaborators, Hartman notes.
“That’s how the collaboration began,” she adds.
The collaborators, Rick Sabousky, PhD, chair of the Department of Special Education at Clarion University, and Ray Feroz, PhD, CRC, LPC, professor and chair of the Department of Human Services, Rehabilitation, Health, and Sports Sciences at Clarion University, looked closely at case management consumers’ sources of support. Sabousky, Feroz, Marks, and Patrick Sanphy presented the tool at the National Association of Case Management Conference, Sept. 21-23, 2015, in New Orleans.
“If case management is making a difference, we should see people move from professional support to less restrictive, more natural support,” Sabousky says. “As we looked at [the issue], I realized it’s very difficult to measure program effectiveness.”
Sabousky asked this basic question: “If people aren’t making progress, how would I know?”
Sabousky and Feroz brought to the task the perspective of program evaluation, individual descriptive planning, and measurable objectives, Feroz says.
“We’ve worked with SAM to take a look at measuring success in terms of what they’re doing with their case managers and their clients,” Feroz adds. “There’s a huge desire in the field for evidence-based practice and efficiency.”
Ideally, the tool would keep CMs focused on looking at a client’s different services and the frequency of those services, he adds.
“We felt it was a good time — during service planning — to get data for these measures, and it also would help reinforce and support case managers’ and consumers’ consideration of all domains of consumer functioning,” Marks says. “It’s designed to reinforce, facilitate, and keep case managers’ heads into the service planning process.”
The collaboration has resulted in a data collection tool that can be used for any population, no matter what an individual’s primary service need, Feroz says.
“We know clients come to us with differing needs; every individual is different. That’s the hallmark of good treatment in case management,” he explains. “What Rick and I wanted to do was develop some sort of measurement in case management that could work across all types of goals and clients and objectives.”
The instrument measures domains and living situations such as housing, family support, cultural, spiritual, social, and recreational issues. It also looks at activities of daily living (ADLs), financial, educational, vocational, legal, drug treatment, mental health, safety, crisis management, mobility, transportation, and other systems involvement and natural support, Feroz says.
“Some clients have a priority in one domain, but no goals in another,” he explains. “We listed everything that contributes to a common service coordination plan, and we measure whether they can do this, they’re adept at it, and whether they have a need for professional services.”
The tool evaluates the following factors on a 0-5 scale:
- 0: The person might receive medication management, but otherwise can receive all natural support and will do fine without professional case management.
- 1: The client might need occasional or quarterly services.
- 2: Intermittent — monthly or less frequently, but more than quarterly — professional services are necessary.
- 3: The client needs intensive professional services of between monthly and weekly support.
- 4: The intensity of services requires ongoing professional support in a community setting of more than weekly.
- 5: The client needs continuous professional services in a clinical setting.
The tool is useful in evaluating an individual person’s independence and need for case management services, as well as the person’s improvement or decline over time. But it also can be used to evaluate how well a case management program or case manager is doing across a CM population, Feroz notes.
“What this scale allows us to do is in a single area like in ADLs, we can keep moving toward improved independence on the part of the client,” he explains. “So if the client is at a 2 in ADLs, we might want to move the client to a 0 — with total natural activities and no need for professional oversight.”
The tool can be an idea-generator for case managers, giving them clues on where they can focus their energy to help clients improve independence. “In a world of evidence-based practice, you can’t be dead in the water,” Feroz says. “You have to show continuous improvement.”
The tool allows case managers to look at modest improvements that still are reasonable goals for individuals in primary interest areas, he adds.
For example, a patient with congestive heart failure (CHF) at onset might need a high level of professionally provided support, including hospitalization and Lasix treatment, Sabousky says.
“I don’t look at hospitalization as a failure,” Sabousky says. “I look at what happens between hospitalizations for someone with chronic health conditions: Maybe the person made some progress and then relapsed.”
For instance, a person with CHF might have reached an improved level of support and could manage self-maintenance with assistance from a spouse, but still calls for help from professionals because the spouse has suddenly taken ill or is less able to help due to other issues. Case management dives into these kinds of nuanced issues, he adds.
In two initial tests of the new tool, case managers appeared to do well with the measurement once they understood the scale and its domains of Living Situation/Housing; Family/Natural Supports; Cultural/Spiritual; Social/Recreational/Leisure; Living Skills; Medical/Health Care; Financial/Insurance; Educational/Learning; Vocational; Legal; Crisis/Safety; Mobility/Transportation, Marks says.
“Case managers already are looking at all domains of a consumer’s life, so it’s really just the nomenclature that we put on to the frequency of services,” Marks says. “We look at every consumer holistically — in all areas of their life, including mental healthcare.”
Case managers use their own electronic equipment to complete the assessment form. So if they carry laptops, they have the tool’s application on the laptop, Hartman says.
The next steps will include training case managers to use the tool as studies of the tool gear up.
“We have to show first that the tool has validity and reliability,” Hartman says. “It’s about bettering case management for everyone; we don’t have a marketing plan or strategic plan around the tool.”
Goals will include better coordination between case management and service providers and a greater focus in case management on quality of life issues for chronically ill clients, Sabousky says.
“Put people in a position to be supported at a level that doesn’t include hospitalization and also have a good quality of life,” he explains. “Say you have someone in a supportive environment who uses professional transportation, and we’d like to see the person begin to use the bus; the person might be more willing to use bus transportation because of the gains from case management.”
The tool’s usefulness hopefully will work on various levels — both in individual case management practice and across populations, Marks says.
“One of the cool aspects of this is we could look at data from the smallest point in time across time,” he adds. “Once the tool is perfected and in place, that flexibility and breadth of view is something we believe could be a really powerful tool.”
Case management work increasingly is being measured, but the big issue is finding tools for effective measurement of CM outcomes.
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