Small Caseload Research Articles

One-Sided Calculation

The study reported by Kutschmann et al (1) shows that the mortality risk for very low birth weight infants is 34% higher in hospitals with less than 30 preterm infants < 1250 g birth weight per year compared to hospitals with higher patient volumes. Since the risk adjusted mortality in many small centers was below average, whereas it was above average in some larger centers, the authors conclude that the caseload is not a suitable indicator of the quality of care. According to the laws of stochastic processes, however, the wide variance of mortality in small centers may actually be the result of the small caseload per center. The lower mortality rate in some small hospitals over a time period of three years may thus be merely an effect of a lower caseload, not an argument against the regionalization of care for very premature infants, which makes sense for various other reasons too. In spite of risk adjustment, mortality was systematically calculated to the disadvantage of perinatal centers. Not including preterm infants admitted more than 24 hours after the birth or those referred to other units (17.5% of the cohort) seemingly leads to lower mortality rates in smaller centers (preterm infants that were transferred to larger centers mostly have severe complications) and a seeming increase in mortality in larger centers (since it is mostly healthy and stable babies that are referred to smaller centers from larger ones). In adjusting the risk, parameters were considered that include poor basic care given to preterm infants (baseline deficit, maximum FiO2) as a risk-increasing factor. These variables reflect, however, the competence of the obstetric and neonatology team; including these into the risk adjustment blurs differences in the treatment quality of different centers. Unfortunately, the differences in mortality were not stratified by gestational age, although the differences between large and small centers have been demonstrated to increase with falling gestational age (2– 4). Such stratification might have provided some answers to the question of the gestational age threshold below which stronger regionalization of the care of preterm infants might be effective.

Intervention design using self-determination theory to promote activity in depressed patients, older adults, and slimmers

Increasingly public health is asking for evidence-based interventions targeted at individuals and their physical activity that are framed in an established behavior change theory. Recently self-determination theory (SDT) has been widely appraised and adopted. Its focus is on understanding and facilitating individual needs satisfaction and it provide a pathway of progression from external to internal motives for lasting behavior change. This is particularly attractive in settings such as physical activity promotion where health professionals are seeking strategies through which they can provide support for long term physical activity gains. This paper provides an exposition of the design and delivery of an intervention to increase physical activity in primary care patients with mild or moderate depression. TREAD was a pragmatic randomized controlled trial delivered in the UK by a physical activity facilitators (PAFs) based in primary care through face-to-face sessions and phone calls over an 8 month period. Targets in the intervention were competence/confidence, autonomy, social support and relatedness. Principles of motivational interviewing were adopted as it encourages patients to take responsibility for their own decision-making and is compatible with SDT. The intervention was successful in increasing physical activity in this challenging population although it did not have a significant impact on depression. Evaluation interviews were conducted with 19 patients at four months and with 12 of them again at 12 months. Patients confirmed that the approach and strategies used by PAFs had helped them feel more able to take charge of their physical activity, feel more competent, supported and more confident in their daily lives and these findings were supported by questionnaire data in the trial. We have also used SDT to underpin intervention design with older adults. Project ACE (Active, Connected and Engaged Neighborhoods) recruits, trains and coordinates volunteering (Activators) active older adults to build a small local case load of sedentary participants who wish to become more active. The intervention uses strategies to build competence and relatedness in the Activators as well as the participants. Finally, the application of SDT in a partnership with a national slimming organization to increase physical activity in women attempting to lose weight is described. Of particular interest is how abstract theoretical concepts are translated into meaning and attractive materials for a population who have given little consideration to exercise. The presentation is aimed at providing pointers to researchers and practitioners wishing to develop physical activity services requiring interaction between professional and patients.

Reduced caseloads improve probation outcomes

Probation practitioners argue that large caseloads limit their effectiveness, but prior research has not supported that assertion. In fact, with exceptions, strong studies of small caseload intensive probation supervision have produced undesirable findings: no reduction in recidivism and increased technical revocations. However, probation standards and practices have changed considerably since this earlier research, suggesting that new studies may yield different results. This study introduced reduced caseloads (approximately 54 medium- to high-risk probationers per officer) into an agency with officers fully trained in implementing evidence-based practices, a combination of supervision strategies based on known predictors of criminal recidivism. We evaluated the intervention's effect on recidivism and technical revocations of probation using a quasi-experimental design (difference-in-differences). We used survival analysis to estimate that the smaller caseload reduced the rate of recidivism by roughly 30%; technical violations increased by 4%. We conclude that reduced caseloads in agencies using modern supervision practices reduce recidivism.

Promoting supervision of midwifery to women

Promoting supervision of midwifery to women

Nurse-led case management for community dwelling older people: an explorative study of models and costs

To compare community matrons with other nurses carrying out case management for impact on service use and costs. In England, nurses working in general practice, as district nurses and disease-specific nurses, undertake use case management. Community matrons were introduced to case management to reduce unplanned hospitalizations of people with complex conditions. Managers in three Primary Care Trusts (PCTs) identified four nurses/matrons engaged in case management. Nurses/matrons recruited five community-dwelling patients referred to them for case management. Patients reported use of health/social services for 9 months, 2008 to 2009. Nurses/matrons completed activity diaries. Service use data were available for 33 patients. Compared with other nurse case managers, community matrons had: smaller caseloads; more patient contact time (mean 364 vs. 80 minutes per patient per month); and older patients (mean age 81 vs. 75 years, P = 0.03) taking more medications (mean 8.9 vs. 5.6, P = 0.014). Monthly costs were significantly higher for patients managed by community matrons (add £861), and who lived alone (add £696). Hospitalizations were not associated with patient or service delivery factors. Further research on cost-effectiveness of case management models is required. The case for continued investment in community matrons remains to be proven.

45 Open retropubic and robotic assisted laparoscopic radical prostatectomy: A comparison of oncological and functional outcome in a county hospital with a small caseload

45 Open retropubic and robotic assisted laparoscopic radical prostatectomy: A comparison of oncological and functional outcome in a county hospital with a small caseload

Occupational Therapy Consultation for Case Managers in Community Mental Health

The purpose of this study was 2-fold: (1) to examine to what extent case managers' job satisfaction and self-efficacy were impacted by the addition of an occupational therapy consultation model and (2) to identify factors that both positively and negatively impacted the occupational therapy consultation services. The study was conducted at a mental health community support program in a local homeless center. In a 2-year study, a mixed-methods design was used to study changes over time in job satisfaction and perceived self-efficacy among 14 case managers who received ongoing occupational therapy consultation. Job satisfaction and self-efficacy data were obtained using standardized questionnaires. Qualitative data related to factors impacting the consultation program were obtained using open-ended written questions, focus groups, and individual interviews. Statistically significant differences in job satisfaction and perceptions of self-efficacy were found 18 months into the study, when case managers were more actively seeking occupational therapy consultation services and were reporting improved client outcomes from occupational therapy intervention. In addition, themes related to both positive and negative factors impacting the occupational therapy consultation program were identified and provided useful data for development of future consultation services. IMPLICATION FOR CASE MANAGEMENT PRACTICE: Results suggest that ongoing training and professional support for case managers who are paraprofessionals and/or new to mental health practice may improve job satisfaction and efficacy. Occupational therapy consultation may be helpful in developing services for health promotion, including self-care management, cognitive assessments, activity-based programming, and home safety evaluation and modification. In addition, new graduates and paraprofessional case managers working with clients who are high utilizers of services may benefit from smaller caseloads and support from clinical professionals.

Analyzing Offense Patterns as a Function of Mental Illness to Test the Criminalization Hypothesis

Analyzing Offense Patterns as a Function of Mental Illness to Test the Criminalization Hypothesis

Staff attitudes and the associations with treatment organisation, clinical practices and outcomes in opioid maintenance treatment

BackgroundIn opioid maintenance treatment (OMT) there are documented treatment differences both between countries and between OMT programmes. Some of these differences have been associated with staff attitudes. The aim of this study was to 1) assess if there were differences in staff attitudes within a national OMT programme, and 2) investigate the associations of staff attitudes with treatment organisation, clinical practices and outcomes.MethodsThis study was a cross-sectional multicentre study. Norwegian OMT staff (n = 140) were invited to participate in this study in 2007 using an instrument measuring attitudes towards OMT. The OMT programme comprised 14 regional centres. Data describing treatment organisation, clinical practices and patient outcomes in these centres were extracted from the annual OMT programme assessment 2007. Centres were divided into three groups based upon mean attitudinal scores and labelled; "rehabilitation-oriented", "harm reduction-oriented" and "intermediate" centres.ResultsAll invited staff (n = 140) participated. Staff attitudes differed between the centres. "Rehabilitation-oriented" centres had smaller caseloads, more frequent urine drug screening and increased case management (interdisciplinary meetings). In addition these centres had less drug use and more social rehabilitation among their patients in terms of long-term living arrangements, unemployment, and social security benefits as main income. "Intermediate" centres had the lowest treatment termination rate.ConclusionsThis study identified marked variations in staff attitudes between the regional centres within a national OMT programme. These variations were associated with measurable differences in caseload, intensity of case management and patient outcomes.

Third ventriculostomy in a single pediatric surgical unit

Endoscopic third ventriculostomy (ETV) is a successful method of treatment for obstructive hydrocephalus that has become popular over the last 20 years. The purpose of this paper is to study the outcome of infants with obstructive hydrocephalus treated by ETV by a single surgeon and to evaluate the safety, reliability, and efficacy of this treatment. All data were collected retrospectively. Between July 1999 and June 2005, 14 children underwent an ETV. In one child, a second ETV was performed. The age of the eight female and six male patients at the time of ETV ranged from less than 1 month up to 13 years and 11 months. The indication for an ETV was an obstructive hydrocephalus. Median follow-up period was 5 years and 9 months. The need of a further operation after ETV was defined as a failure of ETV. In six patients, the first ETV was successful. In the remaining eight patients, there was a need for further treatment (ventriculoperitoneal shunt). Although the follow-up shunt failed in one patient, he was successfully treated by a second ETV. Our study suggests that ETV can be successfully done in a small pediatric unit, but with a lower success rate because of small caseload, and therefore, lower experience and routine of the surgeon. Therefore, we propose a centralization of patients to obtain a higher number of cases. We confirm that ETV is a safe, reliable, and efficient method with a better outcome in children than infants.

Successful engagement: a mixed methods study of the approaches of assertive community treatment and community mental health teams in the REACT trial

The only randomised trial of assertive community treatment (ACT) carried out in England (the "REACT" study: randomised evaluation of assertive community treatment in North London) found no clinically significant advantage over usual care from community mental health teams (CMHTs). However, ACT clients were more satisfied and better engaged with services. To understand these findings better, we investigated the content of care and interventions offered to study participants. Quantitative data were collected to compare team structures and processes. Qualitative interviews with care co-ordinators of 40 of the 251 REACT study participants (20 ACT, 20 CMHT clients) were carried out and thematic analysis was used to explore differences in the approaches of the two types of team. CMHTs scored low for ACT model fidelity and ACTTs scored high or ACT-like. All staff cited client engagement as their primary aim, but ACT approaches were less formal, more frequent and more successful than CMHTs'. Two aspects of ACT appeared important for engagement: small case loads and the team approach. Successful client engagement appeared to be associated with greater staff satisfaction. The findings from this study assist in understanding why the ACT approach is more acceptable to clients deemed by CMHTs as "hard to engage". The key elements of ACT that facilitate client engagement may not be easily replicated within CMHTs due to their larger, varied caseloads.

Beyond Generic Support: Incidence and Impact of Invalidation in Peer Services for Clients With Severe Mental Illness

Beyond Generic Support: Incidence and Impact of Invalidation in Peer Services for Clients With Severe Mental Illness

Evaluating Health Care Performance: Strengths and Limitations of Multilevel Analysis

An increasing number of health services researchers are using multilevel analysis for evaluating health care performance. This method has the distinct advantage of accounting for within-provider correlation among patients. Alternatively, in a similar manner, estimators based on cluster sampling can also adjust for within-provider correlation. Cluster sampling methods do not require assumptions about error distribution as multilevel analysis does. To our knowledge, no comparison has been made between multilevel analysis and cluster sampling estimators in evaluating health care performance using either a simulated or real dataset. In this paper, we compare the cluster sampling estimators to multilevel estimators in evaluating screening mammography performance using Medicare claims data. We also discuss the strengths and limitations of multilevel analysis in profiling health care providers with small caseloads.

Program structure and counselor-client contact in outpatient substance abuse treatment.

To examine organizational structural attributes associated with counselor-client contact. Data were collected in 2004 and 2005 for a federally funded project, which simultaneously examines organizational structure, functioning, and resources among outpatient substance abuse treatment programs. The study uses a naturalistic design to investigate organizational structure measures-ownership, accreditation, and supplemental services-as predictors of time in counseling and case management, and caseload size, controlling for geographic differences. Directors at 116 outpatient drug-free treatment programs located in four regions across the U.S. (Great Lakes, Gulf Coast, Northwest, and Southeast) voluntarily completed a survey about program structure. Clients received more counseling hours in programs that were "intensive," publicly owned, accredited, and had a lower proportion of recently hired counselors. More case management hours were offered in "intensive," private-for-profit or publicly owned (versus private-nonprofit) programs, serving a lower proportion of dual-diagnosis clients, and providing more on-site supplemental services. Smaller caseloads were found in programs that were accredited and had a smaller average client census and a lower proportion of criminal justice referred clients. Organizational attributes are related to counselor-client contact and may have implications for staff turnover and service quality.

Practice size, caseload, deprivation and quality of care of patients with coronary heart disease, hypertension and stroke in primary care: national cross-sectional study

BackgroundReports of higher quality care by higher-volume secondary care providers have fuelled a shift of services from smaller provider units to larger hospitals and units. In the United Kingdom, most patients are managed in primary care. Hence if larger practices provide better quality of care; this would have important implications for the future organization of primary care services. We examined the association between quality of primary care for cardiovascular disease achieved by general practices in England and Scotland by general practice caseload, practice size and area based deprivation measures, using data from the New General Practitioner (GP) Contract.MethodsWe analyzed data from 8,970 general practices with a total registered population of 55,522,778 patients in England and Scotland. We measured practice performance against 26 cardiovascular disease (coronary heart disease, left ventricular disease, and stroke) Quality and Outcomes Framework (QOF) indicators for patients on cardiovascular disease registers and linked this with data on practice characteristics and census data.ResultsDespite wide variations in practice list sizes and deprivation, the prevalence of was remarkably consistent, (coronary heart disease, left ventricular dysfunction, hypertension and cerebrovascular disease was 3.7%; 0.45%; 11.4% and 1.5% respectively). Achievement in quality of care for cardiovascular disease, as measured by QOF, was consistently high regardless of caseload or size with a few notable exceptions: practices with larger list sizes, higher cardiovascular disease caseloads and those in affluent areas had higher achievement of indicators requiring referral for further investigation. For example, small practices achieved lower scores 71.4% than large practices 88.6% (P < 0.0001) for referral for exercise testing and specialist assessment of patients with newly diagnosed angina.ConclusionThe volume-outcome relationship found in hospital settings is not seen between practices in the UK in management of cardiovascular disorders in primary care. Further work is warranted to explain apparently poorer quality achievement in some aspects of cardiovascular management relating to initial diagnosis and management among practices in deprived areas, smaller practices and those with a smaller caseload.

Alphabet Soup in Case Management

Maura J. Lessard is President of Marketing Educational Management Services, MEMS. For more information go to www.MEMSconsulting.net. She can be contacted directly at 413-596-9393 or via e-mail at [email protected]. Kathy Gremel is currently a doctoral student at University of Rhode Island in the College of Nursing. She also serves as a consultant, case manages a small caseload for a community agency serving developmentally delayed children, and teaches at Rhode Island College and New England Institute of Technology. She can be contacted at 401-456-9565 or via e-mail at [email protected].

A Comparison of Assertive Community Treatment and Intensive Case Management for Patients in Rural Areas

A Comparison of Assertive Community Treatment and Intensive Case Management for Patients in Rural Areas

An Innovative Job Placement Model for Unemployed Methadone Patients: A Randomized Clinical Trial

This article presents the outcomes of an innovative vocational rehabilitation model designed for methadone-maintained patients—the Customized Employment Supports (CES) model. CES counselors work intensively with a small caseload of patients to overcome the vocational as well as non-vocational barriers that hinder employment, with the goal of attaining rapid job placement. A randomized clinical trial was implemented at two methadone treatment programs in New York City and was funded by the National Institute on Drug Abuse The study tested the hypothesis that patients assigned to the experimental (CES) condition would have better employment outcomes than those assigned to a control condition who received standard vocational counseling at the programs. The data were collected from May 2001 through April 2005. The efficacy sample for the analysis consisted of 168 patients who completed follow-up interviews. The sample was 58% male, 75% minority group, average age 45 years, and in methadone treatment for an average of five years. The results supported the hypothesis for two measures of employment; i.e., the CES group was significantly more likely than the control group to obtain both any paid employment and informal paid employment. However, there were no significant differences for competitive employment or total earnings. The study's limitations are noted. Implications of the findings for the improvement of vocational rehabilitation for addiction patients are discussed.

Statistical Benchmarks for Process Measures of Quality of Care for Mental and Substance Use Disorders

Statistical Benchmarks for Process Measures of Quality of Care for Mental and Substance Use Disorders

Survey of SLP Caseloads in Washington State Schools: Implications and Strategies for Action

To document statewide and regional caseloads and to examine workload management strategies by surveying speech-language pathologists (SLPs) in Washington State public schools. All school SLPs who were registered with the Office of the Superintendent of Public Instruction were mailed a detailed survey in May, 2001 and a brief follow-up survey 1 year later. Response rates were 43% (N=431) and 47% (N=464), respectively. Caseload findings showed a statewide mean of 59 students, with regional variation as high as 30%. There was no systematic evidence that caseloads were managed through state, district, or local limits or by distributing clients on the basis of the severity of impairment or SLP experience ortraining. There was significant evidence, however, that clinicians with larger caseloads were more likely to have assistants and to conduct a higher proportion of group sessions than were clinicians with smaller caseloads. The authors discuss the implication of these findings for and other states with no caseload limits and a shortage of SLPs. There is an appeal for more research using newly established measures of workload as well as a call to action to address the challenges that these findings represent.