Case Management Staff Research Articles

How case management staff and mothers experienced a transition to medical homes

Public health leaders around the United States are experimenting with a range of models intended to better integrate services for individuals with complex needs. In North Carolina, state agencies recently restructured services for low income pregnant women and young children at risk of developmental delays into medical homes models. The current comparative case study examined how this transition was experienced in communities around the state. Results indicate that: (1) The new program increased the centrality of medical providers; (2) Front line staff re-interpreted policies to fit their public health values; and (3) Case managers struggled with the transition from relational toward rationalized services to mothers. Using a political economy perspective, these changes are interpreted as reflecting shifts in the broader ideological environment. To a large extent, the state appeared to succeed in prescribing more connection between health department-based case managers and community clinical providers. However, limited clinician engagement may constrain the implementation of the envisioned medical homes. The increased focus on medical risk also appears to diverge from mothers’ case management priorities, and may undermine health departments’ role in the local safety net over time by attenuating staff relationships with mothers.

Effectiveness of the Smoking Cessation and Reduction in Pregnancy Treatment (SCRIPT) Dissemination Project: A Science to Prenatal Care Practice Partnership

This study evaluated the effectiveness of the Smoking Cessation and Reduction in Pregnancy Treatment (SCRIPT) Program selected by the West Virginia-Right From The Start Project for state-wide dissemination. A process evaluation documented the fidelity of SCRIPT delivery by Designated Care Coordinators (DCC), licensed nurses and social workers who provide home-based case management to Medicaid-eligible clients in all 55 counties. We implemented a quasi-experimental, non-randomized, matched Comparison (C) Group design. The SCRIPT Experimental E Group (N=259) were all clients in 2009-2010 that wanted to quit, provided a screening carbon monoxide (CO), and received a SCRIPT home visit. The (C) Group was derived from all clients in 2006-2007 who had the same CO assessments as E Group clients and reported receiving cessation counseling. We stratified the baseline CO of E Group clients into 10 strata, and randomly selected the same number of (C) Group clients (N=259) from each matched strata to evaluate the effectiveness of the SCRIPT Program. There were no significant baseline differences in the E and (C) Group. A Process Evaluation documented a significant increase in the fidelity of DCC delivery of SCRIPT Program procedures: from 63% in 2006 to 74% in 2010. Significant increases were documented in the E Group cessation rate (+9.3%) and significant reduction rate (+4.5%), a ≥50% reduction from a baseline CO. Perinatal health case management staff can deliver the SCRIPT Program, and Medicaid-supported clients can change smoking behavior, even very late in pregnancy. When multiple biases were analyzed, we concluded the SCRIPT Dissemination Project was the most plausible reason for the significant changes in behavior.

Case Management Redesign in an Urban Facility

To explore strategies for improving patient throughput and to redesign case management processes to facilitate level of care transitions and safe discharges. Large Urban Medical Center in South Los Angeles County, with 384 licensed beds that services poor, underserved communities. Both qualitative and quantitative methods were applied. Combined theoretical frameworks were used for needs assessment, intervention strategies, and change management. Observations, interviews, surveys, and database extraction methods were used. The sample consisted of case management staff members and several other staff from nursing, social work, and emergency department staff. Postintervention measures indicated improvement in reimbursements for services, reduction in length of stay, increased productivity, improved patients' access to care, and avoiding unnecessary readmission or emergency department visits. Effective change management strategies must consider multiple factors that influence daily operations and service delivery. Creating accountability by using performance measures associated with patient transitions is highlighted by the case study results. The authors developed a process model to assist in identifying and tracking outcome measures related to patient throughput, front-end assessments, and effective patient care transitions. This model can be used in future research to further investigate best case management practices.

Opioid Administration Post-operatively: Reviewing the Process and Identifying Standards and Expectations for Safe, Effective Care

As healthcare faces demands to decrease length of stay and increase patient satisfaction, hospital staff seeks to streamline the discharge process. Evidence suggests an interdisciplinary discharge process results in increased nurse satisfaction, reduced incidence of medical errors and hospital acquired infections. The purpose of the Vascular Surgery and Transplant Unit (VSTU) Discharge by Eleven Project is to identify barriers to discharge and increase efficiency throughout the discharge process. A patient database was developed to detect variables affecting early discharge. An improvement plan was implemented focusing on timeliness of writing discharge orders by surgical residents and early recognition of potential discharge by nursing, medical and casemanagement staff. Subsequently, the ‘VSTUResidentSurvival Guide’was createdhighlighting the expectationsof nurses rounding daily with attending physicians and residents to identify discharges for the next day. Methods of communication included the team leaders, who served as discharge champions, and utilization of the assignment board as a visual cue.Nurseswere instructed to communicate that discharge occurs before eleven to every admission. Discharge times and customer satisfaction scores were posted weekly. The five month study showed an increase in the satisfaction with speed of the discharge process (75 to 89.3) and overall satisfaction with the process (83.6 to 89.3) based on Press Ganey raw scores. The percent of discharges by eleven increased from 11% to 15% and late discharges decreased from 50% to 37%. These findings suggest that by targeting unit specific variables early discharges can be increased.

Palliative Care Case Management

The purpose of this pilot project was to integrate palliative care principles and practices into the day-to-day operations of a Medicaid managed care provider. This was accomplished through the following five activities: (1) employment of an experienced palliative care nurse and social worker to serve as expert role models and consultants to the case management staff; (2) development of a palliative care training curriculum for case managers; (3) provision and evaluation of the training; (4) identification of appropriate patients, provision of palliative care case management (PCCM), and tracking of outcomes; and (5) development of a resource/reference manual for case managers. The project involved a managed care organization providing Medicaid services to patients residing in both urban and rural settings. Expert staff was hired and modeled effective PCCM. This, as well as the training program, had significant influence on both the palliative care knowledge and attitudes of existing case managers. Involved patients demonstrated improved symptom management and satisfaction with care. Patient scenarios demonstrated desirable outcomes in healthcare utilization, and timely, appropriate hospice referrals were realized. Integrating PCCM into the practices of a provider of Medicaid managed care can result in positive patient outcomes, improved utilization of healthcare services, and related savings for the managed care provider. Such a program can increase access to community-based palliative care for Medicaid recipients with life-threatening illnesses. PCCM can address the multiple needs of younger patients with serious illness who are not yet ready to forego curative efforts.

EFFECTS OF TRANSCRANIAL DIRECT CURRENT STIMULATION ON PROBABILISTIC FEEDBACK LEARNING IN PEOPLE WITH SCHIZOPHRENIA

ment to bypass cognitive deficits in patients who have difficulty following a medication regimen. Methods: In study I, 95 outpatients with schizophrenia were randomly assigned to 1) Full-CAT (CAT focused on many aspects of community adaptation), 2) Pharm-CAT (CAT focused only on medication and appointment adherence) or 3) treatment as usual (TAU). Treatment lasted for 9 months, and patientswere followed for 6 months after the withdrawal of home visits. In Study II, a translation study, CAT treatment was delivered by case managers in a community mental health center to 124 consumers for a 9 month period. In study III, in a sample of 92,we compared TAU, to PharmCAT, to a group using smart pill containers that download adherence data to a secure website that can be checked by case management staff. Results: Study I: Results of mixed effects regression models indicated that both CAT and PharmCAT treatments were superior to TAU for improving adherence to prescribed medication. These differences remained significant when home visits were withdrawn. Survival time to relapse or significant exacerbation was significantly longer in both CAT and PharmCAT in comparison to TAU Study II: Adherence improved significantly in the treatment group compared to a group of control individuals in the same clinic. Issues in the implementation of CAT by community agencies were identified and addressed. Assessments were simplified and visit frequency adjusted to fit state mandated guidelines that would allow reimbursement. Adequate reimbursement for time spent in supervision and preparation for visits was also problematic. Study III: Individuals in both the PharmCAT group and the group who received smart pill containers improved with respect to medication adherence in comparison to treatment as usual after only 3 months. Discussion: Interventions using technology may be easier to use in over-burdened delivery systems. Novel treatments to improve adherence delivered in standard community settings may provide a foundation for the individual to more successfully pursue broader goals in their own process of recovery.

Best practices for managing patient service expectations in a reproductive endocrinology (REI) and in vitro fertilization (IVF) program within a health maintenance organization (HMO) setting

OBJECTIVE: Those familiar with HMOs know there are complexities in managing health care services within the managed care (MC) setting. To succeed in improving service within a fee-for-service (FFS) In Vitro Fertilization (IVF) program and a not-for-profit (NFP) Reproductive Endocrinology (REI) practice within a MC setting necessitates a remarkable degree of rigor in order to accomplish the merging of technology and medicine with exceptional quality outcomes. The objective of this abstract is to discuss best practices for managing a shared NFP REI practice and a FFS IVF program within the Kaiser Permanente (KP) HMO setting.DESIGN: Retrospective evaluation based on first-hand knowledge of clinic outcomes and management of a NFP REI practice and a FFS IVF program from January 2007 through May 2008.MATERIALS AND METHODS: Our goal in merging a NFP REI practice and a FFS IVF program was to provide a fuller spectrum of fertility services and continuity of care. Access: Focus on appointment (appt) demand, net loss and demand calculations allow for better appt utilization, access to services and decreased financial net loss. Quality: Quality standards from the IVF lab were established in parallel with the clinic side to maintain consistent quality practices. Staffing: Decentralization of IVF Case Management staff allows for a more consistent level of nursing care at local facilities, improved patient access, better service and physician satisfaction. Charting/Technology: Successful implementation of an electronic medical records program allows clinic to communicate patient information and improved standards of practice for REI and IVF throughout KP. Departmental re-structuring: New positions were developed to allow for a division of work, as well as better utilization of staff. Patient Satisfaction/Service: A variety of patient satisfaction surveys, service contests and team meetings for REI and IVF are used as quality care markers for ensuring consistent patient satisfaction and improved clinic efficiencies.RESULTS: With continued focus, our ability to deliver best practices for REI and IVF is evident by our clinical success rates, quality outcomes, viability of our program, in addition to KP's commitment to expanding both our REI and IVF services within KP.CONCLUSIONS: The nation's leading HMO, KP, has been able to continue to successfully integrate a viable FFS IVF program and NFP REI practice within the MC setting while maintaining the same level of quality, service and accessible personalized care for both. OBJECTIVE: Those familiar with HMOs know there are complexities in managing health care services within the managed care (MC) setting. To succeed in improving service within a fee-for-service (FFS) In Vitro Fertilization (IVF) program and a not-for-profit (NFP) Reproductive Endocrinology (REI) practice within a MC setting necessitates a remarkable degree of rigor in order to accomplish the merging of technology and medicine with exceptional quality outcomes. The objective of this abstract is to discuss best practices for managing a shared NFP REI practice and a FFS IVF program within the Kaiser Permanente (KP) HMO setting. DESIGN: Retrospective evaluation based on first-hand knowledge of clinic outcomes and management of a NFP REI practice and a FFS IVF program from January 2007 through May 2008. MATERIALS AND METHODS: Our goal in merging a NFP REI practice and a FFS IVF program was to provide a fuller spectrum of fertility services and continuity of care. Access: Focus on appointment (appt) demand, net loss and demand calculations allow for better appt utilization, access to services and decreased financial net loss. Quality: Quality standards from the IVF lab were established in parallel with the clinic side to maintain consistent quality practices. Staffing: Decentralization of IVF Case Management staff allows for a more consistent level of nursing care at local facilities, improved patient access, better service and physician satisfaction. Charting/Technology: Successful implementation of an electronic medical records program allows clinic to communicate patient information and improved standards of practice for REI and IVF throughout KP. Departmental re-structuring: New positions were developed to allow for a division of work, as well as better utilization of staff. Patient Satisfaction/Service: A variety of patient satisfaction surveys, service contests and team meetings for REI and IVF are used as quality care markers for ensuring consistent patient satisfaction and improved clinic efficiencies. RESULTS: With continued focus, our ability to deliver best practices for REI and IVF is evident by our clinical success rates, quality outcomes, viability of our program, in addition to KP's commitment to expanding both our REI and IVF services within KP. CONCLUSIONS: The nation's leading HMO, KP, has been able to continue to successfully integrate a viable FFS IVF program and NFP REI practice within the MC setting while maintaining the same level of quality, service and accessible personalized care for both.

Best Practices: A Program to Support Shared Decision Making in an Outpatient Psychiatric Medication Clinic

This column presents preliminary findings of an intervention to support shared decision making in psychopharmacology consultation. The waiting area in an urban psychiatric medication clinic was transformed into a peer-run Decision Support Center featuring a user-friendly, Internet-based software program with which clients could create a one-page computer-generated report for use in the medication consultation. The Decision Support Center was used 662 times by 189 unique users from a young-adult and general adult case management team from October 2006 to September 2007. All clients had severe mental disorders. Only ten clients refused to use the intervention at some point during the pilot study. Focus groups with medical staff (N=4), clients (N=16), case managers (N=14), and peer-specialist staff (N=3) reported that the intervention helped to create efficiencies in the consultation and empower clients to become more involved in treatment-related decision making. A randomized controlled trial is currently in process.

Transforming the traditional discharge planning manual

Discharge planning resources change frequently, and keeping them current, available, and accessible to case management (CM) staff and others is a challenge. Given the time-consuming and labor-intensive nature of updating, many organizations revise them in preparation for the tri-annual survey or when they are hopelessly out-of-date. The reality is that CM staff and others involved with discharges have their own personal "little black book" of resources. Those personal reference tools are treated with reverence and guarded like the family Bible. Organizations are challenged to have up-to-date resources available and accessible for staff in all areas. One approach is to transform the traditional paper-based manual into an electronic document and make it available on the organization's intranet. This approach means that each page of the current paper-based manual must be in electronic format, ending the use of overcopied resources that become difficult to read and "grandfathered in" to each successive edition of the paper manual. This option permits easy and rapid updates when resources and information change.

Emergency Department–specific Case Management Program

Increased use of the emergency department for nonemergent visits results in ED overcrowding, increased length of stay, and poor utilization of health care dollars. The purpose of this project was to implement an emergency department–specific case management program to reduce utilization of nonemergent visits through enhanced patient education and providing linkages to primary care providers and community resources. Implementation of a performance improvement project for emergency department–specific case management. An urban, level II trauma center with 75,000 annual visits. At-risk patients targeted for case management were defined and supported by review of literature and analysis of ED nonemergent patient demographics. A literature search revealed that patients at risk for fragmented health care included those without a primary care provider, those without health benefits, and those enrolled in Medicaid. An analysis of ED utilization for nonemergent visits in this facility correlated with literature findings. Nonemergent is defined by this institution’s reimbursement coding scale, specifically, evaluation and management levels I and II. Implementation of the registered nurse case manager role included identification of at-risk populations for fragmented health care. Networking with hospital and community resources to develop ways to meet the health care and social needs of at-risk populations was completed. Education of nursing staff, liaisons, and ED physicians regarding available resources and emergency department–specific case management principles, including enhanced patient education, was implemented. Evaluation of at-risk population visits shows a decrease in nonemergent visits by 34% (N = 6852) in 2004. A 2004 focus study showed that of 1062 patients referred to this institution’s outpatient clinic 32% (n = 339) made an appointment. Of these 339 patients, 91% (309) kept their appointments. This study reinforces the need to schedule follow-up appointments while the patient is in the emergency department. A 2004 focus study of 50 randomly selected patients who received 1:1 case manager education revealed that 60% (n = 30) had no return visits, 26% (n = 13) had 1 return visit, 8% (n = 4) had 2 return visits, and 6% (n = 3) had 3 return visits. A random study of 50 patients who qualified to receive staff case management education revealed that 58% (n = 29) had no return visits, 20% (n = 10) had 1 return visit, 4% (n = 2) had 2 return visits, 6% (n = 3) had 3 return visits, and 12% (n = 6) had 4 or more return visits. The finding of similar “no return visits” between staff and case manager suggest that case management staff education was effective. However, the increase in 2 or more visits may be related to the inability of staff to schedule follow-up appointments on the off-shift and possible inconsistency of patient case management education by staff. Limitations identified include the need for consistency by staff in case management patient education and the ability of staff to schedule follow-up appointments. Subsequent actions will include the development of an ED Case Management Core Team, thereby giving case management 24/7 coverage. Because the emergency department continues to be the “safety net” for at-risk populations, implications for expanding the emergency department–specific case management program to include individualized patient care plans is indicated.

15. Outpatient DVT Treatment: A Safe, Effective, Cost-saving Alternative Using a Comprehensive ED Protocol

Treating patients with deep vein thrombosis (DVT) in the emergency department on an outpatient basis rather than as an inpatient is preferable because it is less expensive than hospitalization and it allows patients the comfort of recovery at home. However, ED physicians who diagnose DVT have typically been reluctant to send patients home with instructions to take enoxaparin sodium (ie, low molecular weight heparin). The primary concern is that outpatient treatment requires extensive patient education on how to administer self-injections and how to adhere to an explicit follow-up regime. Typically, this type of education is generally unavailable and difficult to accomplish in the emergency department. A secondary concern is the liability aspect of the patient not adhering to follow-up recommendations. To create a situation where outpatient DVT treatment could be safely prescribed for patients who come to the emergency department, a multidisciplinary team comprised of case management, pharmacy, and emergency department staff developed a DVT protocol and discharge instruction plan. ED physicians were educated on when and how to use the plan. ED nurses were educated on discharge instruction contents and how to teach self-injections to the patients using a DVT education cart. This cart contained a TV/VCR, enoxaparin and warfarin videos, and self-injection models. The nursing staff received additional inservices on the DVT protocol and enoxaparin sodium 3 months after the protocol implementation to increase their comfort in giving the comprehensive discharge instructions. Patient follow-up included contacting the patient at home the first day after the ED discharge by the hospital telephone triage department. A set of 6 questions asked during the telephone interview focused on the patient's understanding of the discharge instructions and adherence to the discharge plan. The emergency department successfully discharged 6 patients with uncomplicated cases of DVT home with private physician follow-up plans from September 2003 to March 2004. The protocol seems to be effective in ensuring safe, cost-effective care for patients with DVT because there have not been any adverse outcomes for any of the patients treated as an outpatient. In the advent of stricter guidelines for inpatient admissions, developing protocols, such as the one for outpatient DVT care, is essential to the health care industry so that hospitals and patients can recognize a safe and cost-saving alternative to inpatient therapy. Protocols also standardize the care given to patients and allow them to recuperate in the comfort of home.

Whose Patient Is it Anyway?

This article discussed ways for nurses and case managers to address the challenges of providing care to medically complex patients. By focusing on early identification of patient needs, appropriate referrals can be made by nursing personnel to case management. Nurses are able to impact the outcomes of the patients on a daily basis. However, time and resource constraints often leave nurses with limited ability to provide discharge and follow-up services necessary for complex medical patients. Ideally, nursing and case management can work together to address the entire continuum of care needed by these complex patients. Recognizing how and when to integrate these two professionals in caring for specific types of patients can be challenging. The case studies presented in this article should assist the reader in identifying role expectations and potential patient outcomes. The reader is encouraged to share these case studies with others in the organization struggling to develop and/or integrate nursing and case management services in a seamless process. By recognizing and supporting each other, nursing personnel and case management staff are able to become the advocates that patients need and deserve in order to obtain optimal care.

Cost-effectiveness of case management: experiences of a university managed health care organization.

Effective, multifaceted, and short-term case management services can result in significant, quantifiable cost savings for managed Medicaid, Medicare, and other health care programs. Such savings clearly offset the administrative costs of support for case managers, social services departments, and utilization management services. This report reviews various case management models, the costs for case management staff and resource support, and a number of quantified ways in which a social service and utilization management team model saved significant dollars in a number of different service areas. This cost-benefit analysis financially justifies administrative support for case management services in the budgets of managed Medicaid programs. Case management is a cost-effective and quality of care management tool.

Family-Strengths-Based Intensive Child Case Management

The author presents findings from a project undertaken to explore the implementation of a rural state's family-strengths-based intensive child case management program for families with children with severe emotional and behavioral disabilities. Interviews with 20 child case management staff were conducted for the purpose of examining the extent to which child case managers' perceptions regarding work roles and activities reflected the new family-strengths-based philosophy of children's mental health service delivery. Thematic and content analysis of staff interviews revealed differences in staff perceptions regarding the role of the case manager and a hypothetical case example. The author discusses social work practice implications for the provision of intensive child case management programs and provides recommendations for areas of further inquiry.

Themes and Variations among Seven Comprehensive Perinatal Drug and Alcohol Abuse Treatment Models

In recent years, the prevalence of perinatal chemical dependency has become widespread, .crossing all ethnic and racial lines and every socioeconomic group (Chasnoff, Landress, & Barrett, 1990). Its potential effect on the health of women, children, families, and society has prompted support at the state and federal levels for comprehensive perinatal drug and alcohol treatment models (California Legislature, 1990; Doshan & Bursch, 1982; Graham & Timney, 1990; Jessup & Green, 1987; Novick, 1990; Reed, 1987; U.S. General Accounting Office, 1990). In California, legislation was enacted that funded a novel interdepartmental partnership within the California Health and Welfare Agency. The four agencies involved in this collaborative effort, called Options for Recovery (OFR), were the departments of Alcohol and Drug Programs, Developmental Services, Health Services, and Social Services. The OFR program provided comprehensive perinatal services to more than 2,600 individual pregnant or parenting women at seven pilot sites in both urban and rural parts of the state. The primary OFR program services included case management, residential and intensive outpatient treatment, perinatal medical care, and foster care services. These services were provided in a women-focused, women-sensitive manner to an ethnically and culturally diverse client population. The OFR program also emphasized coordinated service linkages both to prevent service duplication and to ensure that potential service gaps were not left unfilled. A state interagency task force, composed of representatives from the four collaborating state agencies responsible for the OFR program, was established to develop a statewide strategy for addressing the substance abuse treatment needs of pregnant and parenting women and their children. At each of the seven pilot sites, a local lead agency, accountable to the state, was given primary responsibility for implementing the OFR program. The management teams of each pilot project, which at a minimum consisted of alcohol and drug treatment program representatives and case management staff, reported to the local lead agency. Line staff who had ongoing responsibility for providing services for clients included drug and alcohol counselors, case managers, child development specialists, child care workers, parent educators, foster parent recruiters and trainers, mental health workers, and any other service provider that was part of the pilot's OFR program. An evaluation of the OFR program was conducted from 1991 to 1993. On the basis of information obtained through interviews, surveys, and focus groups with OFR staff, clients, and foster parents at all seven pilot sites, as well as quantitative data, the author identified a number of similar treatment and service themes and variations across all seven sites. This article describes both the commonalities and the differences observed during the course of the three-year evaluation. METHODS Qualitative Staff Data In-person interviews were conducted with members of the OFR State Interagency Task Force, staff from both the California Department of Alcohol and Drug Programs and alcohol and drug treatment programs at the local pilot project level, staff from each pilot's local lead agency, managerial and program staff at all pilot sites, foster parent recruiters and trainers, and county social services agency administrators. Interview questions focused on descriptive program information, program philosophy, indicators of success, service provision, staffing, interagency coordination, and program implementation. Program personnel at all seven pilot projects were also surveyed via self-administered, semi-structured survey questionnaires. The survey questions addressed the same issues as the interview as well as professional training and time management. Focus groups were conducted at 18 randomly selected provider sites from the pool of 73 treatment providers that participated in the OFR program. …

MANAGED CARE: An Opportunity for Home Care Agencies

It is clear, even in the future of health care reform, that home care is a growing component of the health care industry. For many years, fee for service was the model reimbursement method. Today we are in a changing health care system that requires a greater emphasis on home care cost containment. New methods of reimbursement are a part of the change. Progressive home care agencies see this as an opportunity to become leaders. This approach does not come without certain risks, however. In taking the risks, it is imperative to minimize the chances for problems, obstacles, and compromising the quality of patient care. It requires that the agency develop a strategy, set a course, and then devote the resources necessary to meet these challenges. Resources may mean investing in upgraded information systems, hiring clinical specialists to develop care plans and protocols, or developing in-house case management staff to allow the agency to monitor use and quality. One thing is clear---the old way of doing business, cost-based fee for service, has a limited life span, and agencies need to embrace these changes, not ignore them.

Intensive child case management: Work roles and activities

This paper presents findings from a project undertaken to explore the implementation of one rural state's intensive child case management program for families with children with severe emotional and behavioral disabilities. Interviews with 20 child case management staff were conducted for the purpose of describing perceived work roles and activities. Thematic and content analysis of staff interviews revealed differences in staff perceptions regarding the role of the case manager, the “ideal” work activities of the case manager, and the barriers to achieving the “ideal” work activities. The discussion focuses on social work practice and policy implications for the provision of intensive child case management programs, and provides recommendations for areas of further inquiry.

The Influence of Career Orientation on Support for Rehabilitation among Correctional Staff

Career orientation and work values were examined as factors that may relate to support for rehabilitation among correctional staff. The study surveyed a representative sample of 332 correctional and case management staff from the five geographical regions of the Federal Correctional Service of Canada. Not surprisingly, correctional officers were found to be less supportive of rehabilitation than case management staff. Among correctional officers, possessing favorable attitudes toward the field of corrections, showing an interest in career development, preferring work that involves people, and desiring work that provides outlets for personal growth were all positive predictors of support for rehabilitation. A desire to work with people was the only significant predictor the authors identified in the smaller sample of case management officers. The results indicated that demographic variables were not helpful in understanding why some correctional workers are more supportive of programming than others. The findings are discussed in terms of the challenges inherent in creating an engaged correctional workforce that supports programming.

Using total quality management in long-term care case management.

Long-term care (LTC) case management has emerged as a way of addressing problems in the long term care system. Case managers serve as links between chronically ill and disabled individuals and the services these individuals need but of which they often are unaware. In this capacity, case managers address the fragmentation in the long-term care system. In guiding clients to cost-effective ways of meeting their long-term care needs, case managers also address the need for cost containment in long-term care. To ensure that case management is effectively addressing these and other problems, attention to quality is essential. However, quality assurance programs too often focus on minutiae rather than on true indicators of quality. In addition, people who are not involved in the related areas frequently make decisions about quality. These decisions impose additional, and sometimes unnecessary, restrictions on the people who are required to implement them. Total quality management (TQM) offers a new approach. In this article, a proposal is made to incorporate TQM principles into LTC case management. The LTC case management demonstration project currently underway in Virginia serves as the case study for this proposal. The proposal demonstrates a process in which quality can be built into a case management system in a way that involves the people who will implement the resultant changes. The proposal shows how case management staff members can learn to identify areas where quality is impaired and to use techniques to aid them in identifying the causes of problems. A procedure for testing solutions and for incorporating the findings into the project is described.

Hospital Case Management: Bridging Acute And Long-Term Care

Since the early 1980s, policymakers and analysts have urged hospitals to be more active in managing the care of their patients beyond the hospital walls. In particular, hospitals have been criticized for failing to address the postdischarge needs of elderly patients with chronic health problems. An influential essay in The New England Journal of Medicine observed that “most of these institutions have no comprehensive geriatric program geared to the long-term medical, rehabilitative, and social needs that are linked to acute illness. To provide quality care, hospitals must make a commitment to long-term care for the chronically ill elderly patient. It is becoming apparent that no one else can.” As part of a strategy for addressing this perceived shortcoming, the authors argued, “Unlike other providers, hospitals could offer comprehensive case management of patients, from home care to acute care, thus ensuring continuity of services.” Under this approach, hospital-based case managers would identify clients, assess their needs, develop care plans, coordinate service delivery, and monitor results. Since many of these activities would take place after the patient left the hospital, hospital-based case management would be a considerable extension of hospitals’ typical discharge planning activities. In part, it was expected that the costs of hospital-based case management programs would be covered through user fees. If the hospital also offered long-term care services, hospital-based case management could generate additional revenues through increased use of these services. If it facilitated the earlier discharge of Medicare patients and reduced Medi-