Thompson, J.M., MacLean, M.B., & Pedlar, D. (2009). Literature Review of Case Management – Basis for Further Research. Veterans Affairs Canada. Charlottetown.pdf

Literature Review of Case Management – Basis for Further Research James M. Thompson, MD CCFP(EM) FCFP Medical Advisor Mary Beth MacLean, BA MA Health Economist David Pedlar PhD Director Research Directorate Veterans Affairs Canada Charlottetown PE Canada 12 February 2009 Research Directorate Techn...

Literature Review of Case Management – Basis for Further Research James M. Thompson, MD CCFP(EM) FCFP Medical Advisor Mary Beth MacLean, BA MA Health Economist David Pedlar PhD Director Research Directorate Veterans Affairs Canada Charlottetown PE Canada 12 February 2009 Research Directorate Technical Report 8 Her Majesty the Queen in Right of Canada, 2009. Cat. No. V32-219/2009E-PDF ISBN 978-1-100-13944-9 Published by: Veterans Affairs Canada 161 Grafton Street Charlottetown, Prince Edward Island C1A 8M9 www.vac-acc.gc.ca Email: [email protected] Correct citation for this publication: Thompson JM, MacLean MB, Pedlar D. Literature Review of Case Management – Basis for Further Research. Veterans Affairs Canada. Charlottetown. 12 February 2009;46 p. Literature Review of Case Management: Basis for Further Research Page 2/42 Literature Review of Case Management – Basis for Further Research James M. Thompson, MD CCFP(EM) FCFP Medical Advisor Mary Beth MacLean, BA MA Health Economist David Pedlar PhD Director Research Directorate, Veterans Affairs Canada, Charlottetown PE Canada 12 February 2009 Contents Executive Summary....................................................................................................... 4 Introduction .................................................................................................................... 6 Methods ......................................................................................................................... 7 Limitations .................................................................................................................. 8 Evidence Synthesis ....................................................................................................... 8 Nature of the Evidence Base ..................................................................................... 8 Definitions of “Case Management” .......................................................................... 10 Core Case Management Functions ......................................................................... 11 Advantages of Case Management........................................................................... 14 Specialized Case Management Models................................................................... 15 Efficacy and Safety of Case Management ............................................................... 18 Economic Evaluation of Case Management ............................................................ 21 Case Management at Veterans Affairs Canada .......................................................... 26 Suggestions for Further Research............................................................................... 29 Individual Client: Identifying Need for Case Management ....................................... 30 Case Management Program Delivery: The Case Mix (Client Groupings) Approach32 Beyond Case Management: Systems Integration (Shared Case Management) ..... 34 Conclusions ................................................................................................................. 35 References and Bibliography ...................................................................................... 35 Appendix 1. Family Medicine case management model: The Four Principles of Family Medicine (College of Family Physicians of Canada) ....................................... 40 Executive Summary The Veterans Affairs Canada (VAC) Research Directorate undertook this literature review of Case Management (CM) to prepare itself to assist VAC with future work, as required. The research questions were developed in consensus fashion by the authors prior to starting the review, and modified as the review progressed and the issues became clearer. The research questions were: 1. What does published evidence say about the nature of Case Management? Specifically: a. What are definitions for Case Management? b. What are the functions of Case Management? c. How has Case Management been organized in various settings for various physical and mental health conditions? 2. What are potentially useful directions for further research in Case Management at VAC? This literature review was conducted collaboratively by a single health economist with long experience in provincial and federal government agencies, a physician with certification and 20 years of clinical experience in Family Medicine, and a researcher whose long VAC career included direct client contact as an Area Counsellor. We conducted a semi-systematic search for literature using PubMed, Google, and reference lists in various VAC and other reports. We included all types of literature for this preliminary review, including descriptive articles, expert single and consensus opinion statements, unpublished government reports, and peer-reviewed publications. Special attention was paid to peer-reviewed critical appraisals of the evidence where available. We tended to specifically exclude examples of CM implementation that did not directly apply to providing services or health care to Veterans. This literature review was limited. Books were not searched systematically, and there are many textbooks on CM. There is a very large literature on the efficacy, safety and economic evaluation of CM for very specific settings and disorders, and we were not able to review that base in detail. Instead, we focussed on reviews. Evidence was informally graded using a standard approach. The synthesis was narrative. Core functions of CM: As in other complex areas of modern health care system 1. Collaborative development of design, the literature on CM is a mix of individual or an individualized case plan. consensus description and expert opinion, backed by 2. Monitoring client’s progress heterogeneous, incomplete scientific evidence. This is against the case plan. not different from the situation for comprehensive 3. Planned disengagement. approaches to the management of disabilities (Thompson and MacLean 2009), except that in the case of CM evidence, even the expert opinion is somewhat fragmented. There is, however, consensus on the core functions of CM: collaborative development of an individualized case plan, monitoring of the client’s progress against the case plan, and planned disengagement. Literature Review of Case Management: Basis for Further Research Page 4/42 Veterans Affairs Canada (VAC) has been providing CM to Veterans since the Veterans Charter implemented 60 years ago in the Second World War, when Medical Social Workers and Casualty Officers coordinated services for clients and their families. Canadian family physicians formalized concepts of CM during the 1960s to create the discipline of Family Medicine, administered by the College of Family Physicians of Canada. During the 1970s, CM practiced by nurses, social workers and other professions evolved to meet pressing needs of patients and institutions in acute care hospitals, mental health systems and workers’ compensation. There is no single model for CM, although all models Although CM implementations share the core functions of identification, collaborative commonly share case planning, case manager/client relationship, needs assessment, monitoring and disengagement, collaborative development of a case plan, service they vary in other functions. facilitation, interdisciplinary collaboration, monitoring case plan, and disengagement. The case plan particularly distinguishes case management from other types of support. Specific implementations vary depending on the nature of the clientele, and the setting. Case Management in health care is not the domain of any single health care profession. Nurses, social workers, occupational therapists, physicians and others practice various forms of case management. Some, like family physicians, have standards within their own profession for unique types of case management. Case Management is standardized in Canada and the US by national and regional associations that are becoming increasingly organized, with credentialing examinations. CM has been used in a wide variety of settings, including CM is widely thought to be an hospitals, outpatient systems, workplaces, the military and effective means for promoting Veterans administrations; and to assist persons dealing with the health of patients, a wide variety of physical and mental health conditions. caregivers and families facing There is wide expert consensus, and limited scientific bewildering challenges for a evidence, supporting the opinion that in general, variety of social, physical, and coordinated, collaborative client-centered CM can benefit mental health issues in a wide patients/clients with complex health issues, their families and variety of settings. caregivers, and organizations providing services to them. Benefits to patients/clients may include improved access to quality care, improved satisfaction, and improved health, family and social outcomes. Benefits of CM may include improved client health and social outcomes, improved service delivery, improved resource consumption efficiencies, and optimum alignment of service delivery with the organization’s goals. Evidence on the costThere is limited literature on the economic evaluation of effectiveness of CM is mixed CM, and no systematic reviews of the quality of the and mainly concentrated in evaluations could be found. Abstracts for nine articles one setting: serious mental found on PubMed with an analysis of costs were health problems. reviewed; only four were full economic evaluations i.e., analysis of costs and consequences. Many were simply cost descriptions. Evidence on the cost-effectiveness of case-management is mixed and mainly concentrated in one setting: serious mental health problems. The quality of the limited economic evaluations is unknown as a full quality review would need to be conducted. Literature Review of Case Management: Basis for Further Research Page 5/42 VAC’s implementations of CM for modern programs as described in VPPM Volume 1 are consistent with the evidence found in this review. Although not called CM in 1945, the DVA (Department of Veterans Affairs) approach to rehabilitation for Second World War Veterans was also consistent with principles later recognized as modern CM. This review provided us with a basis for Further research: suggesting three lines of potential future 1. Method to identify clients needing CM. research: identifying individual clients likely to 2. Use of case-mix (client groupings). benefit from CM, management of CM 3. Toward a single treatment plan. programs using case mix (client groupings), and ways to contribute to a single treatment plan in collaboration with other agencies also providing CM to the same shared client/patient. Introduction “Case management (CM)” is a useful concept, but challenging to define and study. It is neither quite a profession nor a discipline and, as Rosen and Teesson (2001) point out, it is not a unitary concept. However, CM practice requires sufficiently discrete skills and knowledge that certification programs exist in both Canada and the US. No wonder confusion abounds when people discuss CM. Yet, there are core concepts, and CM has been around for a long time. Case Management in health care has deep Canadian roots (CHCA 2005, Atlantic Region 2008). CM in various forms has been provided for decades in a wide variety of settings to Canadians and their families, to help them negotiate complex health problems. When a million Canadians came out of uniform at the end of the Second World War, Medical Social Workers and Casualty Officers in Canada’s Department of Veterans Affairs played key roles in the rehabilitation of wounded Veterans by providing CM in close association with treating physicians (Woods 1953, page 352). Their supportive, coordinating role was not called “case management” in that era. Soon after World War II, the College of Family Physicians of Canada (CFPC) developed a broader medical, psychosocial model of CM in the 1950s and 60s that eventually became “Family Medicine”1. Now acknowledged as a specialty2, Family Medicine evolved to meet the need for comprehensive continuity of care and patient advocacy in a system then dominated by specialists, and to broaden health care focus for the individual to include family and community. The CFPC’s Four Principles of Family Medicine (Appendix 1) is an example of comprehensive CM that has been used for many years to guide accreditation of Family Medicine training programs in medical schools, certification of family physicians, and ongoing professional development (continuing education) programs. However, like other independent providers, family physicians alone cannot meet the CM needs of patients with complex health issues. In the 1970s, CM began to evolve as a defined process in health care, now practiced to a developing common standard by several health care professions (CHCA 2005). CM appears to be most highly developed in acute Sixty years after the Second World War, CM continues to evolve as a core element of client-centered service at Veterans Affairs Canada. 1 Established in 1953 as the College of General Practitioners: http://www.cfpc.ca/English/cfpc/communications/50th/history/default.asp?s=1 2 Family Medicine was acknowledged as a specialty by the CFPC Board in March 2007. Literature Review of Case Management: Basis for Further Research Page 6/42 care hospitals, workers’ disability systems, mental health care and multi-facility health care regions, where CM evolved in response to patients’/clients’ experiences with the growing complexity of health care systems on the one hand, and organizations’ challenges with resource limitations on the other. Sixty years after the Second World War, CM continues to evolve as a core element of client services at Veterans Affairs Canada (VAC). The VAC Research Directorate undertook this literature review in order to better understand the Case Management evidence base as a basis for future research, if required. Methods The research questions were finalized by consensus discussion within VAC prior to starting the study: 1. What does published evidence say about the nature of Case Management? Specifically: a. What are definitions for Case Management? b. What are the core functions of Case Management? c. How has Case Management been organized in other settings, and for various physical and mental health conditions? 2. What are potentially useful directions for further research in Case Management at VAC? We conducted a rapid critical review of published literature to support policy development. The literature review and analysis of the evidence was conducted collaboratively by a single health economist with long experience in provincial and federal government agencies, and a physician with certification and 20 years of clinical experience in Family Medicine. Literature searches: Literature searches were conducted independently by two of us (MB and JT) using PubMed and Google and a variety of search terms including “case management”; opportunistic searches of reference lists were followed up in found publications; and additional references were provided by colleagues in VAC (eg, Atlantic Region 2008). Inclusion and exclusion criteria: We primarily sought peer reviewed reports published in journals and textbooks that had significant editorial oversight. Given the vast literature on CM, priority was placed on locating peer-reviewed literature reviews that employed systematic approaches for critical appraisal of medical-scientific evidence, or significant reports that evaluated consensus expert opinion. We did not concentrate on the very large literature analyzing specific CM applications. We included all types of literature for this preliminary review, including descriptive articles, expert single and consensus opinion statements, unpublished government reports, and peer-reviewed publications. We tended to specifically exclude examples of CM implementation that did not directly apply to providing services or health care to military Veterans. Evidence grading: The evidence was rapidly and informally graded using a limited Literature Review of Case Management: Basis for Further Research Page 7/42 approach to critical appraisal of a medical-scientific evidence base.3 Evidence synthesis: We (JT and MB) independently and then jointly synthesized the evidence using a consensus-seeking narrative method rather than a rigorously systematic analytical method, mainly owing to the highly heterogeneous and largely descriptive nature of the evidence base. MB concentrated on economic evaluation, and JT concentrated on clinical efficacy and safety. Peer Review: This draft version was reviewed internally in VAC. Case Examples: A file review was conducted for 10 VAC clients representing various needs for CM. These cases were selected as follows: six WW II or Korean War elderly Veterans (2 with low SMAF scores, 2 with high SMAF, and 2 with no Area Counsellor Assessment so SMAF could not be estimated); and four Canadian Forces Veterans (1 elderly, 1 with SMAF score, 3 with insufficient file information to produce a SMAF score, 2 in the Rehabilitation Program and 2 not in the Rehabilitation Program). Limitations • • • • Reviewer limitations: o Conflict of interest declaration: Both reviewers are VAC employees. o A broad interdisciplinary expert team was not used to gather, grade and synthesize the evidence. The literature search was partially systematic but not exhaustive. o Books were not searched systematically, and only a couple were examined. o There are alternative electronic databases that specialize in CM literature – a professional librarian could be engaged to conduct formal literature searches. Methodology limitations: o Evidence grading was not done in a fully systematic, reproducible fashion. o Synthesis of the evidence was narrative and informal, not systematic and fully documented. o Reviewed abstracts in many cases rather than full papers. Peer review: o Owing to the short timeline provided to produce this report, it has not been internally or externally peer reviewed, as is our usual practice. Evidence Synthesis Nature of the Evidence Base The bulk of the evidence regarding CM has been descriptive, proposing or describing roles for case managers in a variety of settings, physical or mental disorders, or social situations (Table 1). There is considerable expert opinion favouring CM, much of it hampered by the risk of bias The evidence base for CM is owing to conflict of interest. There is considerable rich in favourable opinion but there is not a comprehensive empirical evidence base. Thompson JM van Til L, Pedlar D, MacLean MB. Approach to the critical appraisal of medical- 3 scientific evidence in support of decision-making. Research Directorate Technical Report. DRAFT __ __ 2009;_ p.Unpublished manuscript. Literature Review of Case Management: Basis for Further Research Page 8/42 research literature providing fragmentary evidence regarding the efficacy and safety of CM approaches, hampered by large heterogeneity in CM definitions, settings, organization and evaluation methodology. As for so many complex health care system issues, the evidence base for CM is rich in favourable opinion but lacks a comprehensive, empirical evidence base. Table 1. Nature of case management evidence base. (See Table 4 for economic evaluations.) Reference AADAC 2006 ACMA 2009 Alli et al 2008 Atlantic Region 2008 Burns et al CHCA 2005 Carr 2005 CDSWG 2005 CMCC 2009 CNSAAP 2009 CMSA 2009 Ferguson and Weinberger 1998 Forchuk 2002 Health Canada 2009 Evidence Type Government position statement. Method of derivation unclear: “Case management principles are grounded in the provincial framework, with attention to principles and characteristics of service and are also derived from current research and case management practices.” Professional organization statement, expert consensus. Method of consensus-building/review of evidence unclear. Review of formally conducted critical appraisals of published evidence. Published, peer-reviewed. Consensus opinion of VAC experts, with informally conducted narrative literature review. Unpublished, not peer-reviewed. Systematic literature review and meta-analysis. Published. Peer reviewed. National consensus expert opinion developed in a round table exercise by convening experts from across Canada. Narrative, descriptive literature review. Published. Peer reviewed. Description of CM implementation in a health region. Expert consensus statement, not known if peer-reviewed. Method of consensus-building unclear. Statement developed by conducting a survey, hosting a consensus-seeking meeting of content experts, developing a draft, seeking broad comments on the draft, and revisions based on comments. Not known whether peer-reviewed. Professional organization statement, expert consensus. Method of consensus-building/review of evidence unclear. Literature review of randomized controlled trials. Systematic. Published. Peer reviewed. Qualitative analysis of job descriptions, published, peerreviewed. Literature review and synthesis of both published evidence and expert opinion. Did not grade the evidence formally, but gave priority to higher-level evidence. Sought expert consensus and noted dissenting opinions. Draft report peer reviewed. Literature Review of Case Management: Basis for Further Research Page 9/42 Reference Hebert et al 2005 Hesse et al 2007 Holloway 2001 King 2006 OWCC 2001 Marshall et al 1998 Marshall 2008 NCMN 2008 Rosen and Teesson 2001 Rosenberg and Sajdak Smith and Newton 2007 Terra 2007 VAC 2006a, 2007 Waddell and Burton 2008 Wulff et al 2008 Woods 1953 Zigura and Stuart 2000 Zilke et al 2006 Evidence Type Primary research and descriptive analysis of CM implementation in a region. Book chapter. Not clear whether peer reviewed, but likely. Cochrane review: very formal process for critical appraisal of published scientific evidence. Expert opinion narrative literature review. Systematic critical appraisal of randomized controlled trials of intensive case management in mental health. Expert consensus statement, not known if peer-reviewed. Method of consensus-building unclear. Cochrane review: very formal process for critical appraisal of published scientific evidence. Expert opinion narrative literature review. Draft consensus statement. Method of consensus-building unclear. Narrative literature review (essay style). Descriptive statement, opinion of two experts. Systematic literature review. Published. Peer reviewed. Systematic literature review. Published. Peer reviewed. Government policy statement. Evidence base not shown. Formal literature review with inclusion/exclusion criteria, evidence graded, narrative synthesis with statements of strength of evidence. Expert opinion when published evidence insufficient. Systematic literature review. Published. Peer reviewed. Narrative based on government files and various publications. Meta-analysis of published literature. Published. Peer reviewed. ___ Published. Peer reviewed. Definitions of “Case Management” Definitions for “Case Management” have been evolving continuously for decades. Even today, definitions for specific CM implementations vary around the core functions (Table 2), depending on the nature of the organization and its clientele. Definitions for specific CM implementations vary around the core functions, depending on the nature of the organization or program, and its clientele, and the goals sought by the specific program. The following definition, attributed to the Commission on Certification of Insurance Rehabilitation Specialists 1992, is widely quoted and used by various organizations and agencies: Literature Review of Case Management: Basis for Further Research Page 10/42 “... a collaborative process which assesses, plans, implements, coordinates, monitors and evaluates the options and services to meet an individual's health care needs using community resources available to provide quality and costeffective outcomes." This widely accepted early definition forms a basis from which to consider the many CM variations developed since the early 1990s in a variety of settings, for a variety of disorders. We have not yet discovered the historical roots of the definition. It is tempting to speculate that modern CM evolved from prior clinical approaches. In 2005, a Canadian national round table adopted this definition for CM with respect to home care (CHCA 2005): “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.” The U.S. Veterans Administration uses this definition: "... that aspect of primary care that coordinates cases across all settings. It is patient-centred rather than disease specific. The VA care manager coordinates care for all diseases and episodes of illness for a particular patient by integrating an assessment of living conditions, family dynamics, and cultural background into the patient's plan of case." VA Directive, 1997. In a literature review of CM conducted as a basis for finding optimum approaches to managing chronic physical diseases such as congestive heart failure, Ferguson and Weinberger (1998) defined CM as: “... a program that uses physician or non-physician providers to maintain continuous contact with patients via telephone or in home visits in order to prevent disease exacerbation through intensive assessment and education techniques.” VAC (2006a, Atlantic Region 2008) defined case management as: “... a method of service for working with clients and caregivers who require and request assistance to solve problems and issues that prevent them from being as independent they would like to be ... a method of service whereby the Area Counsellor, the Interdisciplinary Team, and other professionals assess needs with the client, family and caregivers. Some of the most common Case Management functions are Assessment, Case Planning, Monitoring, Referral, Advocacy, Reassessment, Follow -up, and Termination.” Core Case Management Functions In our review of the CM literature, we found common themes that appear to define CM functions or features (Table 2). A definition for a particular implementation of CM could be created by using the checkboxes in the first column of Table 2. Some functions Literature Review of Case Management: Basis for Further Research Page 11/42 appear to be core to nearly all CM implementations or descriptions, as indicated by the arrows in the first column. Table 2. Case management functions. See Function Note* → Screening to identify patients/clients needing CM → Direct client/patient contact by the case manager → Client centering/focusing → Collaborating between client and case manager Assessing client’s problems and needs in broad context of family and society → Development of case plan Critical thinking Advocacy: supporting client’s rights within funding and legislative frameworks, and outside agencies/providers → Implementation of case plan and monitoring progress Providing direct client care (eg, counselling, psychotherapy, or other treatments) Familiarity with applicable resources/services inside and outside organization Efficient use of resources/services; resource management Reference NCMN (2008), Mullahy (2003), Canadian Forces (2008), OWCC (2001), CNSAAP (2007), OMH (2005), CHCA (2005), VAC (2006a) Terra (2007), Couturier (2008), Mullahy (2003), CCMC (2008), Canadian Forces (2008), CNSAAP (2007), OMH (2005), VAC (2006a), Atlantic Region (2008) NCMN (2008), Forchuk et al. (2002), Mullahy (2003), CCMC (2008), Canadian Forces (2008), OWCC (2001), CNSAAP (2007), OMH (2005), AADAC (2006), CHCA (2005), VAC (2006a) NCMN (2008), CCMC (2008), Carr (2005), Canadian Forces (2008), CNSAAP (2007), OMH (2005), VAC (2006a) NCMN (2008), Mullahy (2003), CCMC (2008), Canadian Forces (2008), OWCC (2001), CNSAAP (2007), OMH (2005), CHCA (2005), VAC (2006a) NCMN (2008), Canadian Forces (2008), OWCC (2001), CNSAAP (2007), OMH (2005), AADAC (2006), CHCA (2005), Atlantic Region (2008) Atlantic Region (2008) NCMN (2008), ACMA (2008), Carr (2005), OMH (2005), AADAC (2006), CHCA (2005), VAC (2006a) NCMN (2008), Mullahy (2003), Canadian Forces (2008), OWCC (2001), CNSAAP (2007), OMH (2005), AADAC (2006), VAC (2006a) Forchuk et al. (2002), CCMC (2008), CNSAAP (2007), OMH (2005), VAC (2006a), Atlantic Region (2008) CNSAAP (2007), OMH (2005), VAC (2006a) NCMN (2008), Couturier (2008), Mullahy (2003), ACMA (2008), CCMC (2008), Carr (2005), VAC (2006a) Literature Review of Case Management: Basis for Further Research Page 12/42 See Function Note* Collaborating and coordinating with family, caregivers and → interdisciplinary care providers; Ensuring continuity of care → Brokering or facilitating services Facilitating communication among health care providers Influencing the social and health care system and environment around the client Promoting provision of quality, effective and safe treatments → CM disengagement Participating in accountability, outcome evaluation Reference NCMN (2008), Couturier (2008), Rosenberg and Sajdak, Mullahy (2003), ACMA (2008), CCMC (2008), Carr (2005), Canadian Forces (2008), OWCC (2001), CNSAAP (2007), OMH (2005), AADAC (2006). Atlantic Region (2008) NCMN (2008), Couturier (2008), Mullahy (2003), ACMA (2008), CCMC (2008), Carr (2005), Canadian Forces (2008), OWCC (2001), CNSAAP (2007), OMH (2005), AADAC (2006), CHCA (2005), VAC (2006a) NCMN (2008), Couturier (2008), Mullahy (2003), CCMC (2008), Carr (2005), Canadian Forces (2008), OWCC (2001), CNSAAP (2007), OMH (2005), AADAC (2006), CHCA (2005), VAC (2006a) Forchuk et al. (2002), Mullahy (2003), CCMC (2008), Canadian Forces (2008), NCMN (2008), Terra (2007), Mullahy (2003), CCMC (2008), OWCC (2001), CNSAAP (2007), OMH (2005) OWCC (2001), OMH (2005), CHCA (2005), VAC (2006a) ACMA (2008), CCMC (2008), OWCC (2001), OMH (2005), CHCA (2005), VAC (2006a) *Arrows indicate those core functions that appear to be most common to nearly all CM implementations. Open check boxes designate functions that appear to vary between implementations. Forchuk et al. (2002) analyzed 29 mental health case manager job descriptions identifying three common characteristics of the case manager’s role: 1. Focus on the client as an individual. 2. Focus on the system around the client. 3. Provide articulation between the individual and the system around the client. They found that expectations of the case managers were extensive, including providing direct care to the individual client as well as community education, organizing, planning and networking. Rosenberg and Sajdak (undated) succinctly summarized optimum CM with this statement: “Properly done, case management can align the interests of the patient, the physician and the payor alike”. They noted these common elements of CM: • • Reflect the needs of target populations. Identify resources needed to meet individual needs. Literature Review of Case Management: Basis for Further Research Page 13/42 • • • Influence health care utilization. Focus on organization and sequencing of services. Use multiple health care disciplines. The American Case Management Association’s standards of practice (ACMA 2008) emphasize these broad factors: • • • • • • • Collaboration Advocacy Communication Resource Management Facilitation Accountability Coordination The Ontario Ministry of Health produced evidence-based consensus standards for intensive CM in mental health (OMH 2005) which identified these core functions: • • • • • Outreach and Consumer Identification Assessment and Planning Direct Service Provision/Intervention Monitoring, Evaluation and Follow-up Information, Liaison, Advocacy, Consultation and Collaboration Advantages of Case Management Table 3 lists advantages of CM mentioned by various sources. Much of the evidence is anecdotal, however there is a large volume of literature objectively analyzing various CM models. We have not critically appraised that literature. Table 3. Purported advantages of case management (incomplete). Advantage Improved client/patient satisfaction Client gets a professional guide Improved health care provider satisfaction Focus on full spectrum of clients’ needs Knowledge transfer to client, clients’ health care providers and payors Improved continuity of care Improved quality of care Improved client compliance with treatment Improved clinical outcomes, including independence. References (incomplete) Terra (2007), Mullahy (2003), CHCA (2005), OWCC (2001), OMH (2005), Terra (2007), OWCC (2001), OWCC (2001), OWCC (2001), CHCA (2005), Terra (2007), Mullahy (2003), CCMC (2008), OWCC (2001), CHCA (2005), Terra (2007), Mullahy (2003), CCMC (2008), CHCA (2005), Literature Review of Case Management: Basis for Further Research Page 14/42 Advantage Reduced requirement for longer duration of service provision or higher resource consumption Reduced costs Alignment with organizational strategy Promotes client’s independence, improves quality of life and independence Responsive to changing client needs Decreased caregiver burden Decreased resource duplication Can respond to an unstable, changing situation References (incomplete) Terra (2007), Mullahy (2003), CCMC (2008), CHCA (2005), Terra (2007), Mullahy (2003), CCMC (2008), Terra (2007), Mullahy (2003), CCMC (2008), NCMN (2008), CCMC (2008), OMH (2005), OMH (2005), CHCA (2005), CHCA (2005), (CHCA 2005), Specialized Case Management Models While the core CM functions appear to be fairly common to many applications, CM roles tend to specialize in various settings, and for various physical and mental health conditions. This section explores the evidence to learn about features of specialized CM models. Specialized Case Management Functions by Setting 1. Acute Care Hospitals Starting in the 1970s, acute care hospitals were among the first organizations to feel intense pressure to juggle skyrocketing cost, tightening resources, fragmenting health care and increasingly complicated clinical challenges. It is not surprising that some of the most advanced CM models evolved in acute care hospitals. Terra (2007) systematically reviewed the evidence for CM models preferred in acute care facilities. Terra found that no single model was preferred, but that key factors in successful models included: • • • • Direct patient contact by case managers. Use of social workers as well as nurses. Recognition of physicians as valued partners. Effectiveness measurable and indicated by: o Reduced length of stay (LOS) o Improved quality of care o Improved continuity of care (reduced de-fragmentation) o Improved patient and physician satisfaction o Reduction in costs. o Improved clinical outcomes. o Alignment with organizational strategy Literature Review of Case Management: Basis for Further Research Page 15/42 Thomas (2008) found in a retrospective study that statistically significant reductions in length of stay in a large Midwest hospital had been achieved using a “full immersion” model of CM across clinical specialties and levels of care, compared to a less intensive traditional model. Complementing acute care hospital CM, home care CM models have also developed (CHCA 2005). A Canadian national roundtable concluded: “there was general agreement that CM is not an independent function or designated to a specific discipline. Rather, it is a strategy or process1 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.” 2. Mental health There is a very large descriptive and partly analytical literature on CM in mental health. One of the dramatic solutions to problems faced by institutional facilities in the 1960s was to reduce psychiatric lengths of stay and reduce inpatient beds, essentially returning care to non-hospital, community-based mental health systems (Marshall et al 1998). Mental health inpatient systems began moving patients back to the community sooner. CM models were developed to help mental health patients cope in outpatient settings, and to reduce hospital utilization. Holloway and Carson (2001) recognized CM and its derivative Assertive Community Treatment as major innovations in mental health care. Burns et al (2007) examined the efficacy of Intensive CM, another CM model in mental health. The Ontario Ministry of Health developed comprehensive standards for intensive CM (OMH 2005). One Ontario health region, to assist clients with dual mental health and substance use diagnoses (concurrent disorders), described their application of CM this way: “Support is provided through a full range of CM services, including intensive CM. Services are tailored to meet the unique needs of the individual and consumer choice and empowerment are key to all services offered. Services include: assistance in obtaining and maintaining housing, teaching daily living skills, assessments and goal planning, 24hour crisis support, referrals to community resources, medication monitoring, and assistance with symptom management, family support, advocacy, and trusteeship. The program also provides vocational training and support and educational groups in life skills, computers and interpersonal skills” (CDSWG 2005). Special CM solutions have been proposed for patients/clients with both mental health conditions and substance use problems (Health Canada 2009, CDSWG 2005, AADAC 2006). Persons with dual diagnosis usually receive treatment from two different agencies. Coordinated assessment and treatment is preferred. 3. Disability Management Disability Management is a specialized set of approaches to dealing with disability in the workplace, typically with the goal of returning workers to employment. There is a large descriptive and partly analytic literature on the roles and functions of case managers in workplace disability management (Thompson and MacLean 2009). CM has been promoted as an effective way to decrease lost time, reduce employers’ disability insurance costs, and improve opportunities for ill and injured workers to return to employment. Waddell and Burton (2008) noted that “evidence-based disease Literature Review of Case Management: Basis for Further Research Page 16/42 management” and “case management” are two different multidisciplinary approaches to workplace disability management. 4. Managed Care Mullahy (2003) pointed out that managed care is a system of cost containment, and CM is one process used in managed care. Managed care models evolved in the health insurance industry primarily to control costs. Rosenberg and Sajdak outline the challenges unique to managed care, arguing that CM is a way to align patient, physician and payor. Mullahy (2003) explains how case managers work within managed care business models not as claims police, but to ensure cost-effective treatment, coordinate care, collaborate and advocate for the individual client, and educate client, providers and payor. 5. Frail Elderly. Hebert et al (2005, page 90) describe how the roles of case managers evolved differently in three sub-regions working to improve service coordination for persons with threatened or weakened autonomy owing to health problems. In one, the case managers reported to a central service coordination committee rather than individual inpatient facilities, facilitating inter-facility coordination. In two others, the case managers were social workers or human resources staff. The authors argued that without full implementation of a multidisciplinary CM function, full service integration and therefore full benefit would be less likely. Couturier et al (2008) concluded that CM can enable better continuity of service for frail elderly, and that it works best when local organizations take ownership and adapt it to local settings. They recognized that various models could be implemented which variably emphasized clinical versus service-brokering aspects of CM, as required for the local situation. They noted such adaptation worked best when: a. The situation was reviewed prior to implementation, taking note of effective continuity practices in real conditions, and to understand everyone’s expectations. b. The plan was framed explicitly in terms of needs to be met. c. They analyzed ahead of time how the plan would be implemented. d. They modified working conditions that would hinder implementation. 6. Canadian Forces. The Canadian Forces (CF) has more than 40 Case Managers designed to help eligible CF members identify and access health, pension and other related resources and to ensure continuity of care (Canadian Forces 2008). Their website defines CM this way: “a program to inform (members) of the services and benefits available to ill and injured members.” It is available to all CF members who have a medical condition or illness requiring CM. The Case Manager meets with the member, assesses their health needs, develops a case plan, helps the member meet their goals, monitors their progress and works with the member to decide when CM is no longer needed. Literature Review of Case Management: Basis for Further Research Page 17/42 Specialized Case Management Functions by Physical and Mental Health Conditions Specialized CM models have been developed for many specific disorders (list incomplete): Diabetes mellitus. Congestive heart failure. Disabilities arising from musculoskeletal injuries. Mental health disorders. Dual diagnosis (concurrent disorders): mental health and addictions. AIDS. Cancer. These conditions require very comprehensive, highly technical expertise and complex ongoing treatments, hence the use of CM to help patients deal with them. Efficacy and Safety of Case Management The literature analyzing CM efficacy and safety is heterogeneous and challenging to synthesize. As Alli et al (2008) point out, the variety of definitions of CM present a challenge to summarizing efficacy and safety. The literature analyzing CM efficacy and safety is heterogeneous and challenging to synthesize. There is notable lack of data on safety, but intuitively it seems that patients/clients who are being case managed are more likely to be more closely monitored for adverse outcomes than those who are not. Ferguson and Weinberger (1998) conducted a systematic literature review of the effectiveness of primary care CM on health care resource use, patient satisfaction, quality of life, functional status and cost-effectiveness. Nine studies met their inclusion criteria. They found that the two successful programs targeted patients with specific diseases and were run by medical subspecialists. Studies of CM in general patients or programs run by generalists did not show proof of clinical benefit. They concluded “While CM programs offer theoretical benefits, few examples of successful programs were found. Positive effect was related to disease condition and specialty training of study personnel. Patient-centered outcomes were often improved upon but at unknown cost. Further multi-site clinical trials are needed to define CM’s role in our future health care system.” In an accompanying editorial, Nash (1998) pointed out that lack of evidence is not evidence that CM is not effective. He noted the broad anecdotal experience many hospital nurses and physicians have with beneficial case conferences and planned patient monitoring, wondering whether randomized controlled trials may be too rigorous for testing the efficacy and safety of complex health programs like CM. Zilke et al (2006) described the development of an interdisciplinary CM program for modern combat Veterans in Alabama. Evaluation of the first year of the program found it to be efficient and effective, however details were not provided in the abstract. Hesse et al (2007) conducted a Cochrane Review for CM for persons with substance use disorders. They concluded that CM effectively linked people with substance abuse to community and treatment services as compared to treatment as usual or other viable Literature Review of Case Management: Basis for Further Research Page 18/42 treatment options, such as psycho-education or brief interventions. However, “seven studies with 2391 participants did not find a clear reduction in illicit drug use with CM compared with usual treatment; similarly with alcohol use (two studies). A single, large trial showed that CM for heroin users was superior to psycho-education and drug counselling in reducing drug use. The extent of linkage varied significantly between studies, which is likely to be influenced by the availability of services in the community, the model of CM, how effectively it is applied and its integration in the local network of services.” Waddell and Burton (2008) found, for workplace disability management, “moderate” evidence that the use of CM approaches, including return to work coordinators, is clinically- and cost-effective for occupational outcomes. Alli et al (2008) appraised the evidence for whether CM improved diabetes outcomes, finding reviews of more than 60 randomized controlled trials of CM for this disorder alone. On balance, they felt the answer was “yes – case-managed patients with type 2 diabetes had lower HbA1c”. However, they noted inconsistency in outcome studies, and broad heterogeneity in CM definitions and study approaches. They emphasized the importance of a coordinated, collaborative multidisciplinary team approach. They did not discuss safety issues. All interventions may have both beneficial and risky impacts on clients and their families. This is true also for CM, which may be regarded as an intervention. While there are many compelling advantages to CM (Table 3), it is also possible to imagine negative outcomes in some cases as a result of well-intentioned CM. We watched for studies that investigated or described safety issues, but the topic was rarely addressed. There is considerable published evidence regarding CM in mental health. Marshall et al (1998) conducted a Cochrane Review of CM for people with severe mental disorders. Their conclusions: “Case management ensures that more people remain in contact with psychiatric services (one extra person remains in contact for every 15 people who receive case management), but it also increases hospital admission rates. Present evidence suggests that CM also increases duration of hospital admissions, but this is not certain. Whilst there is some evidence that CM improves compliance, it does not produce clinically significant improvement in mental state, social functioning, or quality of life. There is no evidence that CM improves outcome on any other clinical or social variables. Present evidence suggests that CM increases health care costs, perhaps substantially, although this is not certain. In summary, therefore, CM is an intervention of questionable value, to the extent that it is doubtful whether it should be offered by community psychiatric services. It is hard to see how policy makers who subscribe to an evidence-based approach can justify retaining CM as 'the cornerstone' of community mental health care. CM is compared to the main alternative approach (ACT) in a forthcoming Cochrane review.” In another Cochrane Review, Marshall et al (1998) studied the evidence for assertive community treatment for people with severe mental disorders. “Assertive Community Treatment (ACT) was developed in the early 1970s as a response to the closing down of psychiatric hospitals. ACT is a team-based approach aiming at keeping ill people in contact with services, reducing hospital Literature Review of Case Management: Basis for Further Research Page 19/42 admissions and improving outcome, especially social functioning and quality of life ... ACT is a clinically effective approach to managing the care of severely mentally ill people in the community. ACT, if correctly targeted on high users of in-patient care, can substantially reduce the costs of hospital care whilst improving outcome and patient satisfaction. Policy makers, clinicians, and consumers should support the setting up of ACT teams.” Ziguras and Stewart (2000) conducted a metanalysis of the effectiveness of mental health CM over the prior 20 years. Assertive community treatment and clinical CM lead to small to moderate improvements in the effectiveness of mental health services. Assertive community treatment had some advantages over clinical CM in reducing hospitalization. Holloway and Carson (2001) pointed to the lack of evidence testing its efficacy in mental health care. They conducted a literature review, finding that the CM concept had evolved over the prior decade, but no controlled trial had been published exploring CM where the case manager is a service broker without responsibility for providing direct care. They also noted that principles of CM had been incorporated into routine mental health care. They urged caution in applying findings to practice in different systems of health and social care, and pointed out that CM is not in itself an effective treatment for severe mental illness. Rosen and Teesson (2002) reviewed the literature on psychiatric CM. They found strong evidence for the efficacy, effectiveness and cost-effectiveness of CM in psychiatry, the closer it conforms to a form of CM known as “active” or “assertive” community treatment. They raised concern, however, that evidence may have been misused, and prone to bias introduced by conflict of interest. King (2006) conducted a critical re-appraisal of the scientific evidence for the clinical and social effectiveness of intensive CM. He noted that the evidence favouring intensive CM in mental health had been established to a moderate level of strength of evidence. He reviewed randomized controlled trials, finding weakening in the clinical and cost effectiveness of ICM. He wondered whether this may be due to fidelity of implementation (a process we call “drift”), effects of researcher allegiance, and shifts in the wider service environment. Smith and Newton (2007) updated earlier Cochrane Collaboration reviews of CM in mental health by conducting a systematic literature review from 1995. They found 60 papers, 39 reports of experimental trials of types of CM, and 21 reviews or discussion papers. The evidence for engagement of services was consistently positive, but evidence for other outcomes was inconsistent, and the strength of findings for CM weakened over time. Assertive types of CM (assertive community treatment and intensive CM) were more effective than standard CM in reducing the total number of days spent in hospital, improving engagement, compliance, independent living and patient satisfaction. They singled out the importance of two issues: understanding the clinical criteria for CM, and the need to demonstrate CM effectiveness. Burns et al (2007) conducted both systematic review and meta-regression to study the efficacy of intensive CM in mental health. They found that intensive CM worked best when participants tended to use a lot of hospital care and than when Literature Review of Case Management: Basis for Further Research Page 20/42 they did not. They suggested that when hospital use was high, intensive CM could reduce it, but it was less successful when hospital use was already low. Wulff et al (2008) conducted a critical appraisal of the literature, finding few studies on the efficacy of CM in cancer care. The literature was so heterogeneous that they were unable to draw conclusions. They described CM as a “black box”, and called for more rigorous trials to shed light on the problem. Marshall (2008) reviewed in an editorial 40 years of research on Intensive CM in mental health. Some of the findings may well apply to CM in other settings. “The effectiveness of Intensive CM was limited to improving patient satisfaction and reducing attrition. Intensive CM teams organised according to the Assertive Community Treatment model offered the additional benefit of reducing days in hospital, but only when the team's clients had been high users of hospital care over the previous 12 months. Four important lessons can be drawn:” “a) Changes to the process of care tend to affect process variables, not outcome variables. “b) Complex interventions must be defined meticulously in clear terminology, “c) Researchers must demonstrate that complex interventions have been properly implemented in clinical trials. “d) It is important to remember that in a clinical trial a successful outcome is determined as much by the control group as by the intervention.” Economic Evaluation of Case Management Economic evaluation deals with input and outputs or costs Economic evaluation deals and consequences of activities. It also concerns itself with with the choices, costs and choices. The role of government is to choose between consequences of policies and programs on the basis of their consistency interventions. with the public interest. The task of policy formulation involves the identification and measurement of all these benefits and costs, and their aggregation in such a way as to determine whether the policy is on balance good or bad. Economic evaluation compares the costs (inputs) of a program or intervention to the consequences (outputs or outcomes). The outcomes might be measured in terms of lives saved, days of ill health averted, or disabilities reduced by a health program or other interventions. The costs are resources used by the program or intervention human time, energy and skills and physical resources. In general, establishing the effectiveness of interventions is a prerequisite for an economic evaluation. Economic evaluation ordinarily should follow three other types of evaluation: Economic evaluation ordinarily follows research establishing clinical efficacy and safety, but may proceed simultaneously. 1. Can CM work in theory? This type of evaluation tests, in theory, the efficacy and safety of a proposed intervention, such as a particular implementation of CM. Could the proposed intervention do more good than harm to people who fully comply with the process? Literature Review of Case Management: Basis for Further Research Page 21/42 2. Does CM work in practice? This type of evaluation tests both the efficacy and safety of a service and its acceptance by those whom it is given. Does it do more good than harm? 3. Is CM reaching those who need it? This type of evaluation tests availability or reach (adapted from Drummond 1987). Is CM accessible to all people who are eligible for the program, and could benefit from it? For CM, there is incomplete empirical evidence to answer questions 1 and 2 with a high degree of certainty, however the great difficulties in applying strict scientific procedures such as randomized controlled trials to a complex process like CM, as discussed earlier in this report, means that evidence for efficacy and safety must also come from a variety of alternative measures including expert opinion and anecdotal evidence controlled for bias. The applicability of evidence from studies in one setting to others is made difficult by the large heterogeneity in CM definitions, settings, organizational/program goals and evaluation methodology. As in other complex health system solutions, economic evaluation necessarily must progress at the same time as studies of clinical efficacy and safety, which is less than ideal. Types of Economic Evaluations There are five main forms of economic evaluations: 1. 2. 3. 4. 5. Cost analysis, Cost-minimization analysis, Cost-effectiveness analysis, Cost-utility analysis and Cost-benefit analysis. A cost analysis compares two or more alternatives but is only a partial evaluation as it does not consider the consequences of the alternatives examined. An economic evaluation can be partial or full as well. Often an article may be titled as a costeffectiveness or cost-benefit analysis but they are really a cost description of cost analysis and did not relate the cost to the consequences and it is therefore a partial evaluation (See Figure 1). Cost-effectiveness is used in the case where alternative programs or interventions have the same outcome of interest, for example, reduced disability days or earlier return to work. Cost-benefit analysis is used when the consequences of alternatives are not identical or are multiple. If benefits are not identical or are multiple then the effects such as disability days avoided, life-years gained, and medical complications avoided must be translated into their dollar benefit in order to compare alternatives. Literature Review of Case Management: Basis for Further Research Page 22/42 Figure 1: Types of economic evaluations. Are both costs (inputs) and consequences (outputs) of the alternatives examined? Is there comparison of two or more alternatives? NO NO YES Examines only consequences Examines only costs PARTIAL EVALUATION Outcome description YES Cost description PARTIAL EVALUATION Cost-outcome description PARTIAL EVALUATION Efficacy or effectiveness evaluation Cost analysis FULL ECONOMIC EVALUATION Cost-minimization analysis Cost-effectiveness analysis Cost -utility analysis Cost-benefits analysis Source: adapted from Methods for the Economic Evaluation of Health Care Programmes, M Drummond, G Stoddart and G Torrance, Oxford University Press, 1987. Nature and Quality of Economic Evaluations of Case Management Drummond et al (1987) outlines ten main questions to ask in the critical assessment of economic evaluations. 1. 2. 3. 4. Was a well–defined question posed in answerable form? Was a comprehensive description of the competing alternatives given? Was there evidence that the programs’ effectiveness had been established? Were all the important and relevant costs and consequences for each alternative identified? 5. Were cost and consequences measured accurately in appropriate physical units? 6. Were costs and consequences valued credibly? 7. Were costs and consequences adjusted for differential timing? 8. Was an incremental analysis of costs and consequences of alternatives performed? 9. Was a sensitivity analysis performed? and 10. Did the presentation and discussion of study results include all issues of concern to users? There is limited literature on the economic evaluation of CM and no systematic reviews of the quality of the evaluations could be found. Abstracts for nine articles found on PubMed with an analysis of costs were reviewed and only four were full economic evaluations i.e., analysis of costs and consequences. Many were simply cost descriptions. Ferguson and Weinberger (1998) conducted a systematic literature review of the effectiveness of CM on health care resource use, patient satisfaction, quality of life, functional status and cost-effectiveness in primary care. Nine studies met their inclusion criteria. On cost-effectiveness they concluded “Patient-centered outcomes were often improved upon but at unknown cost.”. Literature Review of Case Management: Basis for Further Research Page 23/42 The US VA (2000) performed a technology assessment of the impacts of CM and found that all articles in their review that had an analysis of costs or cost-effectiveness analysis wer