Home Care Case Management: Invitational Roundtable, March 3–4, 2005: Summary of Proceedings

Prepared by Canadian Home Care Association
For Health Canada
March 2005

Preface and Acknowledgements

The Canadian Home Care Association (CHCA) is a national, not-for-profit membership organization over 600 organizations and individuals from the publicly funded Home Care programs, not-for profit and proprietary service agencies, consumers, researchers, educators and others with an interest in Home Care. Through ongoing dialogue, publications, and position papers the CHCA acts as a united voice and access point for information and knowledge for Home Care across Canada.

In support of one of the CHCA's strategic initiatives this Roundtable was conducted to provide information and recommendations for health policy planners and administrators, government and health care leaders, and others who are interested in promoting the recommendations on Home Care contained in the 2004 10-year plan to strengthen health care.

The Canadian Home Care Association (CHCA) is enormously grateful to the Roundtable participants and presenters who contributed their time to provide ideas and direction on case management in home care.

The Canadian Home Care Association Board of Directors provided invaluable guidance and direction throughout the project and extends a special thank you to Marg McAlister, MMC Consulting for her facilitation of the Roundtable and writing of the final report.

It is our intention that this report will serve as a basis for discussion and further learning of home care case management in each province and territory.

Nadine Henningsen
Executive Director
Canadian Home Care Association
March 2005

Alternative Formats

Executive Summary

Responding to the growing recognition of the importance of case management nationally, provincially and territorially, the Canadian Home Care Association (CHCA), with the support of Health Canada, hosted an Invitational Roundtable on Case Management. Participants to the discussion included home care leaders from every province and territory. The goal of the meeting was to define case management and in so doing develop a common understanding about case management within the federal /provincial /territorial home care programs.

Participants worked collaboratively to define the principles and elements of case management while recognizing the importance of maintaining a flexible framework which can be applied broadly depending upon each jurisdictional context. The Roundtable dialogue built upon the sharing of experiences and best practices across the country. While each provincial and territorial home and community care program differs in scope, access and content, the single unifying element of all programs is case management.

Throughout the Roundtable discussions there was general agreement that case management is not an independent function or designated to a specific discipline. Rather, it is a strategy or processFootnote 1 undertaken by all health care professionals; and indeed a strategy that clients themselves employ to varying degrees depending on their context and position within the health care continuum. Case management is a strategy for maximizing client wellness and autonomy, within their context, through advocacy, communication, education, identification of service resources and service facilitation. Case management is built into all health professionals' scope of practice. The case manager, as part of a team, helps to identify appropriate services and options throughout the health care continuum, while balancing effective resource utilization in order to optimize value for the client and the system.

Case Management is a collaborative client-driven strategy for the provision of quality health and support services through the effective and efficient use of available resources in order to support the client's achievement of goals related to healthy life and living in the context of the person and their ability.

Roundtable participants identified the principles that guide case management to be:

As a strategy to support health care and effective use of available resources, forum participants identified the following key elements of case management, regardless of the case management model.

Home care case management plays a role in some transitions; in gate keeping, resource utilization, and resource management. Case management varies in intensity according to client needs and is shared between the health practitioner (which includes the case manager) and the client/caregivers.

The case manager, as part of a team, helps to identify appropriate services and options throughout the health care continuum, while balancing effective resource utilization in order to optimize value for the client and the system. Typical outcomes of case management were reported by participants to include:

However, these outcomes are difficult to quantify and/or prove that they are a result of case management intervention. Participants concurred that there is a risk to suggesting that case management can be accountable for outcomes that in fact are dependent on the rest of the health care team and on the system in which the health care service operates. Indicators specific to case management, need to be carefully selected and implemented in order to avoid wrongly attributing to case management results that are team or system dependent.

As the health care system continues to evolve and adapt to new challenges such as chronic disease management and systems integration, case management will become a vital factor in the effective and efficient functioning of our health care system. In the home care sector, the employment of the case management as a strategy for maximizing client wellness and autonomy will be enhanced through a common understanding of the definition, principles and outcomes of case management.

This report represents the integration and synthesis of the information and discussion shared at the Roundtable. CHCA hopes that it will provide federal, provincial and territorial home care stakeholders with a common definition and will also provide a guide to creating context specific models for case management; stimulate the development of case manager core competencies and influence human resources recruitment and retention strategies.

Building a greater understanding of the role of case management in systems integration will enable the capturing of best practices for the use of case management in home care programs in order to achieve improved delivery of health care services for acute, chronic and palliative clients.

The CHCA as a national voice for home care across Canada can play a key role in informing and influencing change by sharing a common understanding of case management to shape an overarching framework under which the provinces and territories can plan and develop their unique programs.

Situational Context

The achievement of "health and wellness" requires many inter-related services including health prevention, promotion and protection, diagnosis, treatment/cure, rehabilitation, support and maintenance, and social adaptation and integrationFootnote 2. Home care is uniquely positioned within our health care system to provide these components and services along the health care continuum and to function as a bridge between the various settings of care, whether they are the acute care hospital, the long term care facility, respite care or the physician's office place.

The Canadian Home Care Association defines home care as an array of services for people of all ages, provided in the home and community setting, that encompasses health promotion and teaching, curative intervention, end-of-life care, rehabilitation, support and maintenance, social adaptation and integration and support for the informal (family) caregiver. Home care programs often integrate the delivery of health care services in the home setting with the broad myriad of community services (i.e. meal delivery services, day programs, respite care facilities, visiting and other volunteer services, transportation services and personal support which in some provinces is considered a community service).

While each provincial and territorial home and community care program differs in scope, access and content, the single unifying element of all programs is case management. Case management addresses the challenge of matching client identified needs and choices with services often offered by multiple agencies, and within increasingly limited health care resources. This process is essential to ensuring the well being of the client while serving as the link between positive health outcomes, community resources and fiscal accountability.Footnote 3

The November 2002 Romanow report, Building on Values: the Future of Health Care in Canada recognized the role and value of case management. The report notes that all provinces and territories offer some assessment and case management as part of home care services and recommends that "coverage for post-acute home care should include case management, health professional services and medication management". Additionally, the report recommended that "case management be included in the coverage as part of home care mental health services".

In 2004, the Federal/ Provincial/ Territorial 10 Year Plan to Strengthen Health Care, identified case management as a core service in the home care baskets to which First Ministers agreed to provide first dollar coverage by 2006.

Responding to the growing recognition of the importance of case management nationally, provincially and territorially, the CHCA with the support of Health Canada undertook a consultation with home care leaders from every province and territory to define case management and in so doing develop a common understanding about case management within the federal /provincial /territorial home care programs and with their respective health care and community partners. The results of the consultation are captured in this report to Health Canada. A description of the undertaking is available at Appendix 1.

This report represents the integration and synthesis of the information and discussion shared at the Roundtable. CHCA hopes that it will provide federal, provincial and territorial home care stakeholders with a common definition and will also provide a guide to creating context specific models for case management; stimulate the development of case manager core competencies and influence human resources recruitment and retention strategies.

Building a greater understanding of the role of case management in systems integration will enable the capturing of best practices for the use of case management in home care programs in order to achieve improved delivery of health care services for acute, chronic and palliative clients.

Roundtable Discussions

Case Management: A Systems Approach

Sholom Globerman, Philosopher in Residence at the Baycrest Centre for Geriatric Care provided an overall commentary on health care systems and the role of case management in a systems structure. Key points from his presentation are described.

Case Management: A Regional / District Approach

In order to move towards a common understanding of case management, the broad dialogue was enhanced with a series of presentations to showcase diverse approaches to the challenge of regional systems integration and case management. The presentations were from British ColumbiaFootnote 4, AlbertaFootnote 5 and the United KingdomFootnote 6. As information was shared and impressions formed, subsequent questions and group discussions were pursued.

While intuitively understood to be important, there are a number of ways in which case management is understood and operationalized.

The Health Regions of Interior Health and Vancouver Coastal Health, in British Columbia shared their home care case management model impressing upon participants the importance of recognizing that case management operates within the client context and is "client-driven". It uses a population health model framework to describe the health status and characteristics of the clients within the communities served. Case management is described as a process that operates within a continuum of health that spans wellness to complex acute episodes where clients experience an acute unstable health episode and require intensive care management. Along the continuum are an ever-increasing number of individuals with chronic conditions who benefit from case management directed at maximizing independence and preventing deterioration.

"All clients need their care managed.... Not all clients ne a case manager."

(Case Management in B.C. 2005)

Calgary Health Region, having released its Framework for Case Management in June 2004 challenged participants to accept that case management is a "client-centred strategy" that manages "the provision and coordination of care across the [health] continuum" and draws on experience and evidence to achieve client outcomes within available resources.

Case management is a clientcentred strategy that manages the provision and coordination of care across the continuum".

(Framework for Case Management, Calgary Health Region, 2004)

Participants were reminded of the drivers influencing home care and case management - primary health care, chronic disease, primary care, and home care expectations. While case management strategies vary according to circumstances the framework's key concepts include being "client-centred", driven by "quality" and to achieving specific "outcomes".

From the United Kingdom, we learned about the evolution of case management and of the research that had been undertaken in order to inform their case management and policy development. Case management is aimed toward efficiently and effectively coordinating services in order to "improve quality of life and reduce service utilization". Key to effective case management is participation on a team; and providing "pro-active", "client-centred" care that crosses health and social service boundaries.

While cost containment has been a driver in Britain, Ruth Hutt's research on the various models and approaches to case management around the world challenged Roundtable participants to question whether case management actually impacted health system utilization and cost.

Themes and Trends in Case Management

In the Roundtable discussions a number of themes and trends impacting the thinking of case management emerged. These include:

What Is Case Management?

Achieving consensus as to the principles and elements of case management respects the jurisdictional flexibility of home care as a provincial program.

"Case management is not a profession in itself, but an area of practice within one's profession. Its underlying premise is that when an individual reaches the optimum level of wellness and functional capability, everyone benefits: the individuals being served, their support systems, the health care delivery systems and the various reimbursement sources."Footnote 8

Case management can be defined a number of ways based on different models of case management, various target populations, diverse home care organizational structures, and varied program goals.Footnote 9 Definitions include:

The definition for home care case management has arisen from the consultations at the Invitational Roundtable on Case Management. The key words in the definition are highlighted.

A collaborative client-driven strategy for the provision of quality health and support services through the effective and efficient use of available resources in order to support the client's achievement of goals related to healthy life and living in the context of the person and their ability.

Core Principles of Case Management

Roundtable participants concurred that the following principles guide case management. These include:

  1. Case management is centred around and driven by the client/caregivers of all ages. Case management strategies are based on clinical reasoning and a partnering relationship in which professionals work collaboratively with clients and their caregivers, respecting their choices, culture and values. This includes the participation of children and youth in their own health care.

  2. Case management strategies enhance health promotion, illness prevention and risk mitigation through client education and emphasis on health promoting behaviours directed to the client's capacity for self management, self care.

  3. Case management is purposeful incorporating evidence-based practice to ensure quality care and outcomes.

  4. Case management is respectful and collaborative, engaging the family and community resources for needed support.

  5. Case management is creative and innovative and requires effective communication.

  6. Case management is guided by an ethical framework which is primarily embedded in the professional's practice guidelines and considers client rights, beneficence, equity, non-maleficence and autonomy and power imbalances.Footnote 17

  7. Case management advocates on behalf of clients, and promotes self advocacy and independence.

  8. Intensity and type of care management and monitoring varies based on client characteristics and changes in the client's needs within the context of their world.

  9. Case management incorporates principles of population health and the broad determinants of health into its approach.

Key Elements of Case Management

As a strategy to support health care and effective use of available resources, forum participants identified the following key elements of case management, regardless of the case management model.

Competencies

While not specifically sought, discussion amongst Roundtable participants surfaced a preliminary list of specific competencies embodied by professionals employing effective case management strategies. These were generally thought to be achieved through experience within the health care system and include:

Outcomes of Case Management

Case management is a process or strategy directed toward achieving defined goals. Assessment of case management outcomes tends to focus on 'process-related' activities as to date there are no scientifically rigorous measurements of outcomes.

Case management is a strategy for maximizing client wellness and autonomy, within their context, through advocacy, communication, education, identification of service resources and service facilitation. The case manager, as part of a team, helps to identify appropriate services and options throughout the health care continuum, while balancing effective resource utilization in order to optimize value for the client and the system.

Typical outcomes of case management were reported by participants to include:

However, these outcomes are difficult to quantify and/or prove that they are a result of case management intervention. Participants concurred that there is a risk to suggesting that case management can be accountable for outcomes that in fact are dependent on the rest of the health care team and on the system in which the health care service operates. Indicators, specific to case management, need to be carefully selected and implemented in order to avoid wrongly attributing to case management results that are team or system dependent.

Effective evaluation of health care services assesses the outcome of the collective health care team. One does not measure system impact by the contribution of the nurse on the hospital ward; but rather recognizes that to reduce length of stay, for example, one assesses the work of the entire health team. Accordingly attempts to assign system wide cost savings to case management are not valid. "The best case-management arrangements may fail to reduce hospitalization if they are not developed in conjunction with social care and other services needed to maintain people in the community."Footnote 18

The outcomes of a case management strategy embedded within the effort of the health care team are:

There is mixed evidence as to the cost-effectiveness and impact on system utilization of early intervention to provide clients with case management of their chronic disease in order to prevent co-morbidities and delay deterioration. Notwithstanding, there is a great deal of interest in providing case management to patients 'upstream' in order to avoid costs later. Intuitively, it makes sense, but more research is needed.

However, the reality of increasing demand is that health costs will remain unchanged as the next neediest patients who are not case managed access care.Footnote 19

Requirements to Support Effective Case Management

Forum participants articulated a series of environmental, system and human resource requirements that must be in place to support the effective implementation of case management as a strategy for maximizing client wellness and autonomy. Limited resources

Absence of integration incentives within the health care system

Policy Implications

The expectations from First Ministers; escalating chronic disease in Canada and a commitment by health care stakeholders to undertake continuous quality improvement initiatives are driving greater emphasis within the Canadian health care system. As a constant in home care, the principles of case management need to be understood and commonly defined in order to ensure equity across the country.

The CHCA as a national voice for home care across Canada can play a key role in informing and influencing change by sharing a common understanding of the definition, principles and outcomes of case management to shape an overarching framework under which the provinces and territories can plan and develop their unique programs. In so doing the common principles can be relied upon to develop local community responsive programs.

Roundtable participants proposed a number of recommendations to advance a common and consistent understanding and approach to home care case management in Canada.

They felt that their recommendations would address the key challenges articulated. They suggest that the CHCA:

References

Appendix 1

Project Description

The CHCA hosted a stakeholder roundtable to develop consensus on the definition, principles and outcomes of case management in the home care sector in Canada and advise the federal government on the challenges, gaps and policy implications to achieving these outcomes. The roundtable included a broad representation of home care programs and service providers across Canada (see Appendix 2).

Goals

Objectives

The final report will help inform the Provincial / Territorial and Federal activities supporting the 2004 Health Accord and future development of home care programs. The CHCA will disseminate the report to the roundtable participants, CHCA members and home care stakeholders across Canada.

Appendix 2

Glossary of Terms

Advocacy

act of recommending, to plead the cause of another; to speak or write in favor of. (Ref: Case Managements Society of America)

Assessment

a systematic process of data collection and analysis involving multiple elements and sources. (Ref: Case Managements Society of America)

Autonomy

freedom of self-determination (Ref: Webster's Canadian Dictionary)

Beneficence

the principle dictate the need to inflict no harm on clients, to try to inflict benefits, or to ensure that the benefits outweigh the harm. (Ref: Ethical Dilemmas p117)

Canadian Home Care Association

(CHCA) is a national not-for-profit membership Association dedicated to ensuring the availability of accessible, responsive home care and community supports which enable people to stay in their homes with safety, dignity and quality of life. The CHCA represents over 600 organizations involved in home and community care across Canada. Through ongoing dialogue, publications, and position papers we act as a national voice and promote excellence in home care through leadership, awareness and knowledge to shape strategic directions.

Home Care

CHCA defines home care as an array of services, provided in the home and community setting, that encompass health promotion and teaching, curative intervention, end-of-life care, rehabilitation, support and maintenance, social adaptation and integration and support for the informal (family) caregiver. Home care services are for infants, children, adults and seniors. Home care programs often integrate the delivery of health care services in the home setting with community services (e.g. meals on wheels, day programs, respite care facilities, volunteer services, and transportation services).

Client Centred care

planning, treatment and management involves patient, caregivers and advocates at all levels and goals are related to patient outcomes. (Ref: What is the evidence for the effectiveness of managing the hospital/community interface for older people?)

Client Directed service delivery

the need for client choice in making decisions about their requirements, client abilities, and the need to ensure that the service fits the context in which the client lives. (Ref: Client Centered Practice: What Does it Mean and Does It Make a Difference?)

Competency

the skill, ability, knowledge, behaviour and attitude that is instrumental in the delivery of desired results and, consequently, of job performance. (Ref: Pan American Health Organization, 2002.)

Equity

distributive justice (Ref: Ethical Dilemmas p118)

Non-maleficence

doing no harm (Ref: Ethical Dilemmas p118)

Process

intervention taken to achieve the outcome (Ref: Advanced Case Management p 55)

Outcomes

Measurable results of case management interventions, such as client knowledge, adherence, self-care, satisfaction, and attainment of a meaningful lifestyle. (Ref: Case Management Society of America)

Strategy

a unified comprehensive and integrated plan...designed to ensure that the basic objective of the enterprise are achieved. (Ref: Framework for Case Management, p34)

Transitional care

coordinated and continuous planning for health care during transfer of patients between locations or levels of care - e.g., hospitals, acute, post acute and longterm nursing facilities, home, and specialist referral. (Ref: What is the evidence for the effectiveness of managing the hospital/community interface for older people?)

Transition planning

the management of a complex two-way interface between institutions and community-based service providers. The two-way nature of this information exchange implies an on-going and continuous relationship between providers of care, permeable boundaries and the need for enhanced accountability between care providers in different sectors. (Ref: OHCC)

Appendix 3

Roundtable Participants

Footnotes

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