and Case Management
5.3 Model B – Multi-Disciplinary Team Case Management
The key difference between this and the previous model is the absence of a dedicated Case Manager. Rather, on referral to the co-ordinator of services, the needs and wishes of the older person and appropriate informal carers are assessed by a dedicated multi-disciplinary team. A Case Manager is appointed according to the main needs of the older person. For example, if an older person’s needs are mainly for social work services, then the Case Manager for that person will be the social worker on the multi-disciplinary team.
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Model B – Process of Service Delivery
notifies
+
Self
-care and family
assisted care until
older person decides to notify Co-ordinator of services multi- disciplinary team
Meets and assesses care recipient and family Care manager from team appointed according to
client ’s k ey needs GP and PHN/ Social W ork er
Care Plan Specialist Services
On-going implementation and re- assessment of plan Community -based services and
additional services Case manager
,
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Models A and B were presented to a number of key informants in health boards and other agencies working with older people. They were invited to comment on any aspect of the models of Case Management. However, feedback was invited on the following specific aspects:
terminology
the background of a Case Manager (i.e. professional training and work experience) education and training
communication and reporting relationships linking health and social services
devolved budgets
evaluation and assessment
preference for Model A or Model B.
The results of this feedback are provided below.
5.3.1 Terminology
The question of how to describe Care and Case Management and what to call a Case Manager gave rise to mixed responses. Concerns included the need to place more emphasis on the social aspect of care. One person felt that ‘a stronger emphasis needs to be placed on the fact that the needs of older people go beyond those which are … health related’. In terms of the title of the person who would fulfil the Case Management function, concerns were expressed that calling them a Case Manager carries
connotations of depersonalisation of older people into ‘cases’ managed by professionals. Suggestions for different titles included Care Managers or Care Co-ordinators.
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5.3.2 The Background Of A Case Manager
All concerned felt that Case Management entails specific core skills such as counselling, mediation, advocacy, conflict resolution and management skills. However, the question remained of which, if any, professional background a Case Manager should come from. One view was that the allied medical professions, such as occupational therapy, physiotherapy and so on, were not trained in these skills, but that they could undergo extra training in order to acquire them. Another view was that social work was ideally suited to the role of Case Manager, with nursing and occupational therapy also fairly well suited to the role. Some felt that a training programme would be essential to become a Case Manager.
5.3.3 Education And Training
Education and training for Case Managers were seen as extremely important. One view was that without training, there is a danger that the financial and organisational aspects of service provision will take over the process. One person suggested that training ‘on the job’ might be a way of getting around the difficulty of finding fully trained professionals in the first place. For Case Managers who will be working with older people with specific needs for the first time, training was seen as essential, and experience desirable. Key aspects of training cited were:
conflict resolution and negotiation skills counselling skills
advocacy
management skills
knowledge of organisational structures.
5.3.4 Communication And Reporting Relationships
There was a variety of views on different aspects of communication. One person felt that the existing informal communication system could be useful in helping Case Managers to overcome difficulties in creating comprehensive packages of care in a situation of scarce resources. There was concern that formalising communication networks could result in Case Management being driven by costs and budgets. Another respondent looked at the issue of reporting relationships. This person expressed the
view that trying to negotiate existing reporting relationships could be problematic. However, he felt it important that these relationships be clarified, as ‘… the communication of information regarding the needs of those clients and the lack of services will influence planning for the future.’ Necessary improvements in
communication were mentioned, including publicising the service, upgrading communication technologies between different services and standardising record- keeping systems.
5.3.5 Links Between Health And Social Services
This arose as a major area of concern. Respondents felt very strongly that the Irish care system was far too influenced by the medical model of health care, which acted as a block to forming further links with social services. One respondent pointed out that in fact there is no statutory service provision for older people in Ireland, neither is there a Community Care Act like that in the UK. This person was concerned that if this
distinction was not made then Care Management would become a purely health-based approach.
5.3.6 Devolved Budgets
The issue of devolved budgets was described as highly complex. Most were concerned as to what level should budgets be devolved. The experience of Case Managers in the United Kingdom, whose time became increasingly taken up with budgeting and cost control, was identified by one respondent as a lesson from which one can learn. As one person pointed out, ‘… the budget will drive the service, and people will feel forced to cut needs out’. On the other hand, if budgetary control remains at senior management level, there is a danger that Case Managers will have no authority to buy in necessary services and it will become increasingly difficult to co-ordinate the different services, negotiate with service providers and, most importantly, to deliver comprehensive packages of care according to the wishes of the recipients of care.
5.3.7 Evaluation And Assessment
Results from Phase Two of this project indicated that of those working with older people in Ireland (e.g. key professionals, volunteers), almost all were interested in evaluation which focuses on the care recipient. The impact that the programme has on their life, and more specifically their quality of life, was of particular importance. One participant in Phase Two indicated that they felt outcome evaluation should be an ‘individualised process’ suited to the needs to the particular person. This participant also admitted that
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this would certainly complicate any evaluation efforts, but ‘should nevertheless be an integral part of case management’. A few participants emphasised the need to look beyond the traditional ‘medical’ aspects of care, and the need to include social and community factors and supports. While one participant was interested in evaluation that might reveal if the goal of allowing the older person to remain in their own home was met, another participant pointed out that staying at home may not be in a person’s best interest. They felt that setting such a criterion for success (the person remaining at home), might not be the most appropriate or ‘best outcome’ given a particular person’s circumstances. Thus, having such a strict measure of success might be ‘done to the detriment of the person and their carers’. Very few mentioned the financial aspects of evaluation, but those who did agreed that it should be weighed with outcome indicators. Others who participated in Phase Two of the project indicated that they felt that they did not have enough expertise to comment on evaluation methods or tools. These types of comments may indicate a level of need for training in evaluation methods for those who are in a position (such as front-line workers) that may require their engagement in evaluation efforts. Education about how and why they are collecting certain kinds of data may serve to solidify their commitment to evaluation efforts.
5.3.8 Preference for Model A Or Model B
Overall, Model A emerged as the preferred model for the respondents consulted. This was felt to be the case for a number of reasons; firstly that the problems of older people are complex. Another view was that carer’s needs should also be taken into account. The third reason that was cited was that unless there is a designated person with a specific remit to organise care, the person involved may be compromised as he or she seeks to balance their role as Case Manager to a group of older people with their general professional remit. A fourth reason provided was that trained professionals in all areas of current service provision are over-stretched and therefore may not be able to perform the extra commitment of Case Management; and finally it was pointed out that the training of all staff, many of whom may not be interested in Case Management, would not be feasible or cost-effective.
Taking into account this preference for Model A, along with the strong preferences expressed in the focus groups with older people for the presence of one dedicated Case Manager who could act as a point of contact during the care planning and implementation process, and the point made by Challis (1994:63) that in the UK key worker approaches (where a ‘near’ Case Management role is tagged on to a person’s existing job) have ended up aiming to co-ordinate single services or teams with little collaboration between agencies, Model A appears to be the more acceptable option to propose.