Individualized Service Plan Research Articles

Opportunities of integrated care to improve equity for adults with complex needs: a qualitative study of case management in primary care.

People living in precarious socio-economic conditions are at greater risk of developing mental and physical health disorders, and of having complex needs. This places them at risk of health inequity. Addressing social determinants of health (SDH) can contribute to reducing this inequity. Case management in primary care is an integrated care approach which could be an opportunity to better address SDH. The aim of this study is to better understand how case management in primary care may address the SDH of people with complex needs. A case management program (CMP) for people with complex needs was implemented in four urban primary care clinics. A qualitative study was conducted with semi-structured interviews and a focus group with key informants (n = 24). An inductive thematic analysis was carried out to identify emerging themes. Primary care case managers were well-positioned to provide a holistic evaluation of the person's situation, to develop trust with them, and to act as their advocates. These actions helped case managers to better address individuals' unmet social needs (e.g., poor housing, social isolation, difficulty affording transportation, food, medication, etc.). Creating partnerships with the community (e.g., streetworkers) improved the capacity in assisting people with housing relocation, access to transportation, and access to care. Assuming people provide their consent, involving a significant relative or member of their community in an individualized services plan could support people in addressing their social needs. Case management in primary care may better address SDH and improve health equity by developing a trusting relationship with people with complex needs, improving interdisciplinary and intersectoral collaboration and social support. Future research should explore ways to enhance partnerships between primary care and community organizations.

JA ImpleMENTAL Implementing the Belgian Best Practice on Community Mental Health system Reform

Abstract Mental health challenges affect more than one in six people across the EU. In order to support Member States to proceed with mental health care system transformation and suicide prevention JA ImpleMENTAL, was initiated on the request of Member States, on October 2021 under the European Union 3rd Health Program. The JA consists of 39 organizations from 21 countries, more than 180 persons are working. Two advisory bodies support the consortium and provide their insights and expertise, a stakeholder forum with 10 key European Organizations in Mental Health including EUPHA Mental Health Section and WHO Europe and OECD, and the Member State Policy Committee which ensures the involvement of ministries and enables the practices to be embedded in health systems. Within the 11 countries implementing pilots under the Belgium model using a common Implementation Strategy, a total 163 activities are implemented under the 5 following key areas: 62 on structural measures needed for the establishment of local networks promoting a user’s centered, human’s right based recovery approach, 43 for the development and/or transformation of mental health services, 22 on training & capacity building in support of the reform and cultural change, 22 on continuous communication, information and awareness raising, and 13 on data collection, monitoring and evaluation. An analysis of MS pilot action plans shows that most service transformation efforts have concentrated on: defining care pathways for people at risk and for those with mild to severe mental health conditions including smooth transition from child and adolescent to Adult Mental Health services, as well as from inpatient to community services, the nomination of case managers for assisting individuals to their recovery process the development of individual service plans, the Involvement of users in various layers of service delivery including peer support and the provision of assertive treatment through mobile units.

If EQ-5D-5L Mobility Dimension Ratings Are High, Is Life-Space Assessment a Clinically Sensible Next Step? Data from a Population Survey.

Background: Impaired health states can limit a person's mobility, often progressively for people with life-limiting illnesses. Quantifying mobility changes is crucial for individual clinical care and service planning. Objective: To explore any correlation between EQ-5D-5L's mobility dimension ratings and Life-Space Assessment (LSA) from a population sample. Methods: An online population survey of Australian adults, nationally-representative by key demographics. An analysis of variance examined each level of the EQ-5D-5L mobility dimension rating against its LSA scores; Kendall's Tau assessed correlation. Results: Participants (n = 6366) were 53% women, mean age 46.1 years (SD 18.6), and mean LSA score 78.0 (SD = 27.5; possible range 0-120). At each EQ-5D-5L mobility dimension level there was a significant difference between LSA scores (p < 0.001), and a moderate negative correlation (Kendall's tau b = -0.342) between the two measures. Conclusion: Given the relationship defined, EQ-5D-5L mobility dimension ratings may prompt clinicians to consider further evaluation with the more detailed Life-Space Assessment. .

On the edge of the image: Guiding the lenses to the individual service plan

This article seeks to unveil Brazilian Public Policies in the establishment of norms, which in practice act as mechanisms of violence and social exclusion, and are not welcoming to those who are socially marginalized. A qualitative analysis with documental bias revealed Education and Socioeducation actions through secondary source documents, namely, the Individual Service Plan (o Plano Individual de Atendimento − PIA). Four thematic markers were identified which deal with school, work, gender and family. The results revealed that the absence of a political-economic structure can generate family disorders which negatively impact school performance, concluding that the variables are related to the offending behavior of adolescents.

Comparing employment, employment services, and employment goals in propensity-matched samples of people with intellectual and developmental disabilities with and without autism.

People with intellectual and developmental disabilities (IDD) tend to have poor employment outcomes relative to the general population, as do people with autism. Research is unclear, however, about how people with IDD with and without autism compare on a variety of employment-related indicators, including desire to work, having work as a goal in their service plans, and being employed. To understand how people with IDD with and without autism compare on important employment related outcomes, based on a matched random sample. Using merged administrative datasets, we used propensity score matching to construct statistically proximate samples of Medicaid waiver users in a single state with IDD both with and without autism, and then tested differences between the two groups on important employment-related indicators. People with IDD and autism were less likely than people with IDD alone to have a goal for employment in their individualized service plans and to hold employment in group community settings. There was no statistical difference between the two groups in terms of desire to have a job or employment in individual community settings. Results reinforce the importance of planning for employment if holding employment is a person's aim, regardless of the presence of autism.

Implementation analysis of a case management intervention for people with complex care needs in primary care: a multiple case study across Canada

BackgroundCase management is one of the most frequently performed interventions to mitigate the negative effects of high healthcare use on patients, primary care providers and the healthcare system. Reviews have addressed factors influencing case management interventions (CMI) implementation and reported common themes related to the case manager role and activities, collaboration with other primary care providers, CMI training and relationships with the patients. However, the heterogeneity of the settings in which CMI have been implemented may impair the transferability of the findings. Moreover, the underlying factors influencing the first steps of CMI implementation need to be further assessed. This study aimed to evaluate facilitators and barriers of the first implementation steps of a CMI by primary care nurses for people with complex care needs who frequently use healthcare services.MethodsA qualitative multiple case study was conducted including six primary care clinics across four provinces in Canada. In-depth interviews and focus groups with nurse case managers, health services managers, and other primary care providers were conducted. Field notes also formed part of the data. A mixed thematic analysis, deductive and inductive, was carried out.ResultsLeadership of the primary care providers and managers facilitated the first steps of the of CMI implementation, as did the experience and skills of the nurse case managers and capacity development within the teams. The time required to establish CMI was a barrier at the beginning of the CMI implementation. Most nurse case managers expressed apprehension about developing an “individualized services plan” with multiple health professionals and the patient. Clinic team meetings and a nurse case managers community of practice created opportunities to address primary care providers’ concerns. Participants generally perceived the CMI as a comprehensive, adaptable, and organized approach to care, providing more resources and support for patients and better coordination in primary care.ConclusionResults of this study will be useful for decision makers, care providers, patients and researchers who are considering the implementation of CMI in primary care. Providing knowledge about first steps of CMI implementation will also help inform policies and best practices.

Nursing Care Coordination in Primary Healthcare for Patients with Complex Needs: A Comparative Case Study.

Despite nurses' substantial role in care coordination, few education programs exist to better support them in this role. Identification of a set of core care coordination activities across heterogeneous care coordination programs would facilitate the development of a standard of practice. We sought to examine care coordination activities across two care coordination programs in Family Medicine Groups in Quebec, and their relationship to the program design. We performed a comparative case study of two care coordination programs in primary care targeting frequent users of healthcare services and people with Alzheimer's disease and related disorders. Data collection included documents and semi-structured interviews with key informants. Several activities were common to both programs, such as patient identification; assessment, development of an individualized service plan; and linking patients and caregivers with professionals and services. However, their components were different due to the impact of the integrated care program design, policy environment, and the target patient populations' complex needs. The homogeneity or heterogeneity of patients' complex needs shapes their care trajectory and the intensity of their care coordination needs. As the complexity of these needs grows, so does the necessity to build the care coordinators' capacity for integrated care.

Deployment of Mental Health Social Workers in Community Mental Health Centers in Taiwan

&lt;p&gt;社區心理衛生照護模式是以病人居家照護為主軸，提供精神病人社區生活支持體系，協助並結合家庭照顧者的精神疾患的服務模式，推動心理衛生照護的可近性、可及性與在地化，預期至2025年，全國將設置71處社區心理衛生中心，針對心理脆弱族群的早期介入，結合社區資源，因應需求，提升全國的心理健康知能、心理適應、韌力與復原能力。心理衛生社工員（師）評估個案與家庭的核心問題，協調跨專業合作，整合心理衛生、保護性、家庭、司法與法律等社會工作領域，透過個別性的服務計畫，提供連續性、支持 性精神病人照護&lt;/p&gt; &lt;p&gt;&amp;nbsp;&lt;/p&gt;&lt;p&gt;Community mental health care is a medical service model that centers on patient home care, provides psychiatric patients with a community life support system, and involves assistance from family caregivers. This in turn promotes the proximity, accessibility, and localization of mental health care. A total of 71 community mental health centers are expected to be constructed by 2025 to provide early interventions to psychologically vulnerable groups. Accordingly, community resources will be incorporated to fulfill the needs of these groups, improving the mental health literacy, psychological adaptation, and resilience of psychiatric patients across Taiwan. Mental health social workers are tasked with assessing the core problems facing case patients and their families; coordinating interdisciplinary collaborative care; integrating resources from various social work fields, including mental health, protective, family, judicial, and law fields; and providing continual and supportive psychiatric care through individualized service plans. They are also in charge of reinforcing the medical referral system and using multicultural and strength-oriented perspectives in social work to support and assist psychiatric patients in community life.&lt;/p&gt; &lt;p&gt;&amp;nbsp;&lt;/p&gt;

Case Management Programs for Improving Integrated Care for Frequent Users of Healthcare Services: An Implementation Analysis.

Introduction:Case management programs (CMP) for frequent users of healthcare services presenting complex healthcare needs constitute an effective strategy to improve patient experience of integrated care and to decrease healthcare overuse and cost. This study sought to identify characteristics of these programs, and their implementation contexts, that help to improve patient self-management, experience of integrated care, and healthcare services use.Methods:A mixed methods multiple embedded case study design was conducted, with six CMP implemented in six hospitals of a region of Quebec (Canada).Results:Within-case analysis describes the structural, environmental, organizational, practitioner, patient, and innovation level characteristics of each CMP and their services integration outcomes based on patient experience, self-management and healthcare services use. Cross-case analysis suggests that the skills, leadership and experience of the case manager, providers’ access to the individualized services plan, consideration of the needs of the patient and family members, their participation in decision-making, and the self-management approach, impact integrated care and healthcare services use.Conclusion and discussion:This study underscores the necessity of an experienced, knowledgeable and well-trained case manager with interpersonal skills to optimize CMP implementation such that patients are more proactive in their care and their outcomes improve.

Case management programs for people with complex needs: Towards better engagement of community pharmacies and community-based organisations.

The objectives of this study were 1) to describe how case management programs engaged community pharmacies and community-based organisations in a perspective of integrated care for people with complex needs, and 2) to identify enablers, barriers and potential strategies for this engagement. Using a descriptive qualitative design, individual interviews and focus groups with patients, healthcare providers and managers were analysed according to a mixed thematic analysis based on a deductive (Rainbow Model of Integrated Care) and an inductive approach. Participants highlighted the individualized service plan as a significant tool to foster a shared person-focused vision of care, information exchanges and concerted efforts. Openness to collaboration was also considered as an enabler for community stakeholders' engagement. The lack of recognition of community-based organisations by certain providers and the time required to participate in individualized service plans were outlined as barriers to professional integration. Limited opportunities for community stakeholders to be involved in decision-making within case management programs were reported as another constraint to their engagement. Cultural differences between organisations regarding the focus of the intervention (psychosocial vs healthcare needs) and differences in bureaucratic structures and funding mechanisms may negatively affect community stakeholders' engagement. Formal consultation mechanisms and improvement of communication channels between healthcare providers and community stakeholders were suggested as ways to overcome these barriers. Efforts to improve care integration in case management programs should be directed toward the recognition of community stakeholders as co-producers of care and co-builders of social policies across the entire care continuum for people with complex needs.

Determining clinical cutoff scores for the Australian Treatment Outcomes Profile psychological health, physical health and quality of life questions.

The Australian Treatment Outcomes Profile (ATOP) is a brief instrument that measures self-reported substance use, health, and wellbeing in the previous 28 days for people in alcohol and other drug treatment. Previous studies have established the concurrent validity, inter-rater, and test-retest reliability of the tool. The current study sought to identify recommended cutoff scores for ATOP items for psychological health, physical health and quality of life that identify clients reporting clinically significant problems warranting further assessment and/or intervention, compared to cutoffs used by 'gold-standard' measures for these domains. Clients attending for treatment for problems with opioid (n= 144) or alcohol use (n= 134) completed the ATOP and comparison standardised questionnaires (Kessler-10, Short Form Survey 12 and the Personal Wellbeing Index) with a researcher. Receiver operating characteristics analysis, along with clinician perspectives, were used to recommend cutoff scores for ATOP items indicative of clinically significant problems. A cutoff score of 5 or less out of 10 was identified as an optimal pragmatic cutoff for ATOP items relating to psychological health, physical health and quality of life items with regards to balancing sensitivity, specificity, and application in a treatment setting. The recommended clinical cutoffs will support clinicians and treatment services to identify clients who require further assessment and follow up for their psychological health, physical health and quality of life. The current study provides further evidence for the utility of the ATOP for individual clinical review, service planning and research.

Don't Forget the Caregivers! A Discrete Choice Experiment Examining Caregiver Views of Integrated Youth Services.

BackgroundThe design and implementation of community-based integrated youth service hubs (IYSHs) is burgeoning around the world. This collaborative model of care aims to address barriers in youth service access by designing services that meet the needs of youth and caregivers. However, heterogeneity across models requires a better understanding of the preferences for key service characteristics.MethodA discrete choice experiment was conducted among 274 caregivers of youth aged 14–29 years with mental health challenges. The experiment consisted of 12 attributes with four levels each, representing different service components; additional measures were collected, including demographics and burden assessments. Utility values were calculated, representing the degree of preference for a given level of an attribute. Latent class analysis was conducted to understand subgroups with different service preferences, identifying three latent classes with differing IYSH service preferences.ResultsThe largest class (n = 173, 63.1%), entitled ‘Comprehensive, Integrative Service Access’, strongly valued practical aspects of service design, such as rapid access and support for a wide range of needs. The ‘Service Process Features’ class (n = 67, 24.5%) expressed a relative prioritization of process features of service access, while the smaller ‘Caregiver Involvement’ (n = 34, 12.4%) class most highly prioritized caregiver involvement in their youths’ services. Similar demographic characteristics and caregiver burden were found across classes, although participants in the Caregiver Involvement latent class were supporting younger youth.Discussion and ConclusionsCaregivers have diverse youth service preferences and relative priorities that should be taken into account when designing services. System designers and service providers are encouraged to take caregivers’ preferences and priorities into account, alongside youth priorities, whether designing service delivery models or an individual service plan for a youth.Supplementary InformationThe online version contains supplementary material available at 10.1007/s40271-021-00510-6.

Comprehensiveness, Coordination and Continuity in Services Provided to Young Children with Cerebral Palsy and Their Families in Norway

ABSTRACT Background Cerebral palsy (CP) is one of the most common childhood disorders requiring comprehensive and coordinated care over time. This study aimed to add knowledge about health, educational and social services received by children and families throughout early childhood, with special attention on coordination services provided. Methods The study was designed as a prospective longitudinal cohort study utilising data from two CP registers in Norway. Fifty-seven families with children with CP aged 12–57 months with different levels of mobility limitations classified according to the Gross Motor Function Classification System were included. Services were mapped via the parent-reported Habilitation Service questionnaire at least three times. The relationships between mobility limitations and the number of services and type of coordination services were explored using a linear mixed model and Chi Square/Fischer’s exact test. Continuity in the provision of services was explored by identifying interruptions in the longitudinal reports on services received. Results Most of the families received both health, education and social services as well as some types of coordination services. The number and type of services received varied to some extent depending on the children’s mobility limitations. Multidisciplinary team and an individual service plan were widespread coordination services, while having a service coordinator was most common among the families raising a child with severe mobility limitations. Interruptions in the longitudinal reporting of services were frequent, especially in the receiving of coordination services. Conclusion The comprehensiveness of the provided services emphasises the need for coordination services. The relatively low proportion of families provided with a coordinator and the frequent interruptions in the longitudinal reports on services indicate some persistent challenges in the service system.

Leading change in the large-scale implementation of a service integration model in Québec

The International Journal of Integrated Care (IJIC) is an online, open-access, peer-reviewed scientific journal that publishes original articles in the field of integrated care on a continuous basis.IJIC has an Impact Factor of 5.120 (2020 JCR, received in June 2021)

Partnering with Families &amp; Other Natural Supports on Individualized Service Plans (ISPs)

Positive familial support can be a good resource for young people during their transition years. However, family involvement and support during the transition years for young adults with mental health conditions can be complicated by changing family dynamics. This tip sheet describes what we know about partnering with families, offers best practices when working with young adults and their families and providers some resources to learn more.

WORKSHOP RPL KONSELING INDIVIDUAL BERBASIS POP BK SMP/MTs

Workshop on the implementation of POP BK SMP/MTs-based individual counseling services held by MGBK SMP-Banjarbaru City were held with the intention of providing an understanding of the plan for implementing individual counseling services, so that counselor can use the individual counseling service plan properly. This workshop was carried out by presenting the material for the implementation of the service plan and then continued with the simulation of the case study-based manufacture, participants amounted to 38 people. The workshop implementation showed that counselors needed an in-depth understanding to use the plan for implementing individual counseling services as a counselee's initial information.

Case managers in France: Impact of seniority and graduation on practices and professional representations

In France, integrated care is a recent process, initially experimented during the National Alzheimer Plan 2008-2012. One of the key measures of this policy concerned the training of case managers (CMs) for elderly subjects presenting complex situations at home. All CMs received the same formation; they began exercising between 2008 and 2015. Few data are available on their opinions and professional practices. Objectives: 1/description of CMs professional practices and 2/analysis of the influence of seniority and graduation on these practices and CMs opinions on their profession. Methods: A national survey was conducted by questionnaire sent to all CMs between January and February 2016; multivariate analysis of the influence of seniority and graduation on professional practices and opinions was performed. Results: Participation rate was 78% (n = 546). Among the participants, 93% were women (median age 35 years) and 48% had a seniority of more than 2 years. At the time of the survey 52% of the CMs were graduated. On average, each CM was monitoring 23 situations. The CMs whose seniority was > 24 months had more situations in charge: 27± 8 vs 18±9 when the seniority was ≤ to 24 months (p = 0.0005). Those who were graduated also had more situations in charge: 26±8 for graduated vs 17±9 for non-graduated (p = 0.0005). CMs whose seniority was > 24 months seemed less likely to continue with case management when they met with reluctance from the patient (OR 0.4 CI 0.23-0.72 p = 0.002), and reported less often to negotiate with the person upon refusal (OR 0.44 CI 0.22-0.89 p = 0.024). When they encountered difficulties, CMs declared to be more likely to discuss situations with their colleagues rather than with their superiors (OR 1.80 CI 1.01-3.22 p = 0.046). They expressed more frequently the wish to manage fewer situations (OR 1.56 CI 1.08-2.26 p = 0.017). They considered more often that one of the specific contributions of their profession was the strengthening of the ambulatory- hospital links (OR 1.95 CI 1.07-3.57 p = 0.03). Graduated CMs reported less systematic use of the Individualized Service Plan tool than non-graduated (OR 0.43 CI 0.25- 0.75 p = 0.003). They also expressed the wish to manage fewer situations (OR 1.57 CI 1.05-2.25 p = 0.026), and to have more ethical reflection (OR 1.97 CI 1.14-3.39 p = 0.014). They considered more often that the specific contribution of their profession was an improvement in the quality of life of the accompanied persons (OR 2.81 CI 1.07-7.37 p = 0.036). Graduated CMs declared more frequently that they wanted to stop this function in the future (OR 7.78 CI 2.05-29.48 p = 0.003). Conclusion: Seniority and graduation seem to favor certain arrangements with CMs practice and modify representations. Unexpectedly, the graduation does not seem to encourage the CMs in the pursuit of their task. More studies are needed to understand why training does not strengthen CMs in their professional practice.

What does one learn from the implementation of a mandated integrated network for older adults across three different settings in Quebec

Context: In 2004, Quebec mandated its 94 Health and social services centers to lead in the implementation of local integrated health networks. The Health and social services centers, which were created by the fusion of some public establishments (local community health centers, long term care facilities and acute care hospitals in some cases), provide a broad range of health and social services to their populations. To ensure the provision of a comprehensive continuum of care, theses Health and social services centers create partnerships with community organisations, pharmacies and primary healthcare providers of their territories. Objective: To compare the implementation of 3 mandated local integrated health networks for seniors in 3 geographical settings; highly urban, urban and rural. Methods: This research is part of an international research program ICOACH where 3 case studies were carried out in each jurisdiction: Quebec, Ontario and New Zealand. This presentation is based on data collected from 46 semi-structured interviews of healthcare providers and managers in Quebec, as well as the analysis of official documents. Results: The mandated networks for older adults were based on the local implementation of 9 components; 1) a joint governing board, 2) a centralized access point, 3) case management, 4) a common multidisciplinary evaluation tool, 5) an individualized service plan, 6) a common healthcare information system, 7) a geriatric team, 8) the involvement of the family physician in the community and 9) an administrator for the local network. All the main components of the local network were mandated, and several components were implemented with local variations. For instance, each local integrated network for older people had its joint governing board, but the composition and the dynamism of these boards differed considerably. These local integrated networks for older people used the general access point of their Health and social services centers, and in each of these local networks, a common evaluation tool was used to assess the needs of each patient. Services plan would be based on this assessment but a gap can be observed between addressed problems and proposed solutions that are more the services offered by the health and social services centers than by assessed needs. The type of case management varied across networks. For instance, in the highly urban setting, only social workers of the home care team could be case managers while in the urban setting, case managers included different health professionals such as nurses, occupational therapist and social workers. The healthcare information systems were not well implemented. Across the 3 cases studied, few professional teams and healthcare organizations were connected by an information system. Finally, across the 3 cases studied, the primary healthcare practices were not well integrated with public services of the networks. They mostly worked in parallel with respect to the other services of the network. Conclusion: Ten years after the creation of mandated local integrated networks for older people, several implementation challenges are still observed. The implementation of components of the network show local variations and some key components are poorly developed.

Addressing Challenging Behavior in People With Profound Intellectual and Multiple Disabilities: Analyzing the Effects of Daily Practice

AbstractAs some people with profound intellectual and multiple disabilities (PIMD) are at a high risk of developing a challenging behavior, it is useful to look at measures taken to prevent or diminish this type of behavior. The authors undertook a study of how self‐injurious, stereotypical, destructive, or aggressive behaviors are addressed in daily practice in residential facilities. A stratified sample of 30 people with the most severe and frequently reported challenging behaviors was selected from a dataset of 181 children and adults with PIMD. Individual comprehensive service plans were used to determine whether challenging behaviors were present and how these problems were addressed. In total, only 51.8% of the challenging behaviors that occurred were described in the individual plans, and for 53.7% of the challenging behaviors, strategies or interventions were included in the individual service plans. Only 17.2% of the cases contained goals formulated to prevent or diminish such behavior. A significant positive relationship was found between the severity of challenging behavior and the extent to which it was described in the individual comprehensive service plans. The authors also noted that interventions that were aimed at diminishing or preventing challenging behavior were highly simplistic, and virtually no goals were formulated to document, diminish, or prevent challenging behavior in people with PIMD.

Quality of life in children with cerebral palsy: implications for practice.

The ability to assess the quality of life of children with cerebral palsy to inform and evaluate individual care plans, service planning, interventions, and policies is crucial. In this article, the recent evidence on quality of life in children with cerebral palsy is reviewed, with attention to the determinants of quality of life and role of this construct as a practical outcome indicator in clinical trials. Quality of life measurement advances for children with cerebral palsy are discussed with a focus on condition-specific quality of life measures, particularly, the Cerebral Palsy Quality of Life-Child, which is the first condition-specific quality of life measure for children with cerebral palsy. The article presents an overview for clinicians and researchers intending to use quality of life measures on children with cerebral palsy and provides recommendations for future research that will better inform practice in the field.