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Decision Makers’ Allocation of Physical Therapy and Occupational Therapy
Services in Ontario Homecare
By
Abdur Rakib Mohammed
A thesis submitted in conformity with the requirements for the degree of
Masters of Science in Rehabilitation Science
Graduate Department of Rehabilitation Science
Faculty of Medicine
University of Toronto
©Copyright by Abdur Rakib Mohammed (2011)
ii
Decision Makers’ Allocation of Physical Therapy and Occupational Therapy
Services in Ontario Homecare
Masters of Science in Rehabilitation Science
2011
Abdur Rakib Mohammed
Graduate Department of Rehabilitation Science
Faculty of Medicine
University of Toronto
Abstract
Hospital stays have grown increasingly shorter with a corresponding increase in
the use of homecare services. However, we have a limited understanding of how
homecare services are allocated in Ontario, particularly homecare rehabilitation
services. The primary objective of this research is to explore the current decision-
making processes for the allocation of occupational and physical therapy
services in homecare for the long stay clients. To address this objective a
exploratory study using key informant interviews was conducted. The results
indicate that the process of decision making for the allocation of therapy services
is comprised of a series of stages called intake, assessment, referral to service
provider and reassessment. Amongst these the process of determining the
volume of therapy services varies widely across different region. These
variations are primarily due to the regional contextual (e.g. financial constraints)
factors of the individual CCACs.
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Acknowledgements
I am grateful to my investigators and Program Advisors for their support,
encouragement and guidance. Dr. K. Berg’s enthusiasm for health service
research has inspired me to pursue a career in research. Her constructive
comments and countless corrections of my papers have got me through the
program and brought me where I am today. I appreciate her massive time
contribution along the journey of my M.Sc. and I am glad that I had a chance to
learn from her. Dr. S. Rappolt’s expertise in qualitative research has guided me
throughout the process of my data analysis. I am particularly thankful to her for
being the second reader of my interviews. I would also like to extend my
appreciation to Dr. M. Egan for being in my program advisory committee. Her
insight about homecare and rehabilitation literature has shaped the methodology
of my study. I must also express my gratitude to Dr. Jeff Poss for providing
assistance and guidance during the planning phase of my study. His expertise
and insight regarding provincial homecare data holdings have significantly
contributed to my study. Finally I am also thankful to Dr. Cott for being my
internal examiner and Dr. Ploeg for being my external examiner and providing
constructive feedback on my thesis.
I would like to recognize my dearest friend Qin Du for her support and
contribution in improving my writing skills. I am forever in debt to her for her
countless proof reading and corrections to my papers. I also cherish her
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encouragements and trust in me that have been deeply appreciated through out
my career.
Finally I must show my sincere appreciation to the 14 participants and numerous
collaborators from various Community Care Access Centers who volunteered
their time for my research. Without their contribution this work would not have
been possible.
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Table of Contents
Abstract ........................................................................................................................... ii Acknowledgement ....................................................................................................... iii Table of Contents .......................................................................................................... v List of Figures and Tables ........................................................................................... vii List of Appendices ..................................................................................................... viii Chapter 1: Background and Rational ........................................................................... 1 Introduction .................................................................................................................... 1 Literature Review .......................................................................................................... 1
Fall Prevention ............................................................................................................ 3 Chronic Obstructive Pulmonary Disease ................................................................. 6 Rehabilitation Services in Ontario Homecare .......................................................... 9 Regional Variation in Therapy Services Allocation ............................................... 16
Chapter 2: Methodology .............................................................................................. 20 Design ........................................................................................................................... 20 Phase1: The Development Phase ............................................................................... 21
The Interview Guide ................................................................................................. 21 The Vignettes ........................................................................................................... 22 Data Charts .............................................................................................................. 23
Phase 2: The Interview Phase .................................................................................... 24 Sampling ................................................................................................................. 24 Recruitment ............................................................................................................... 25 Case Manager’s Interview ....................................................................................... 26 The Administrator’s interview ................................................................................ 28
Phase 3: Data Analysis ............................................................................................... 29 Analytic Framework .................................................................................................... 29
Familiarization .......................................................................................................... 30 Thematic Analysis ................................................................................................... 30 Indexing ..................................................................................................................... 31 Charting ..................................................................................................................... 31
Chapter 3: Findings .................................................................................................... 32 CCAC Guidelines ........................................................................................................ 32 The Process of Decision-making in CCAC ................................................................ 37
The Intake ................................................................................................................. 38 Source of Referral .................................................................................................. 38 Eligibility for in Home Service ................................................................................ 39 Selection of Clients ................................................................................................ 40
Case Manager’s Assessment ................................................................................. 41 Referral to Service Provider ................................................................................... 43
Volume of Services ................................................................................................ 44
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The Therapy Process ............................................................................................. 46 Increasing Therapy Services ................................................................................. 47
Case Manager’s Reassessment ............................................................................. 48 Factors Affecting CCAC Services ............................................................................. 49
Cost Containment .................................................................................................... 49 Ministry Funding Method for CCAC ........................................................................ 51 Sharing of Client Information ................................................................................. 51 Service Provider’s Model of Service Delivery ....................................................... 52
Reactions to Vignettes ............................................................................................... 53 Vignette A ................................................................................................................. 53
Decision of Referral ............................................................................................... 54 Need for Other Services ........................................................................................ 55 Volume of Services ................................................................................................ 55 Reassessment ........................................................................................................ 55 Increasing Therapy visits ....................................................................................... 56
Vignette B ................................................................................................................. 56 Decision of Referral ............................................................................................... 56 Need for Other Services ........................................................................................ 57 Volume of Services ................................................................................................ 57 Reassessment ........................................................................................................ 57 Increasing Therapy visits ....................................................................................... 57
Response to Aggregate Data Analysis ..................................................................... 57 Chapter 4: Discussion ................................................................................................. 63 Chapter 5: Conclusion ................................................................................................ 72 References .................................................................................................................... 74 Appendices ................................................................................................................... 80
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Lists of Figures and Table Figures Figure 1: The Process of decision making in CCAC ............................................... 37 Figure 2: The Decision Making Funnel ..................................................................... 63 Tables Table 1: Profile of the Sample CCACs ....................................................................... 25 Table 2: A Sample Care Path ..................................................................................... 35 Table 3: Different approaches to determine the Service volume ........................... 45 Table 4: Response to Data Chart ............................................................................... 58
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List of Appendices Appendix 1: Tables and Figures ................................................................................ 80 Appendix 2: The Code Book ....................................................................................... 87 Appendix 3: Data Collection Tools ............................................................................ 90
The Letter of Introduction ........................................................................................ 90 The Consent Form .................................................................................................... 92 The Demographic Profile ......................................................................................... 93 The interview Guide ................................................................................................. 94
1
Chapter 1: Background and Rationale
Introduction
Hospital stays have grown increasingly shorter with a corresponding increase in
the use of post-acute services. The burden of care has shifted to community-
based formal and informal support services (Cott, Falter, Gignac & Badley, 2008;
Gitlin, Hauck, Winter, Dennis, & Schulz, 2006a). There is considerable evidence
of the feasibility and effectiveness of rehabilitation for older persons in home-
based settings (Giusti, 2006; Crotty, 2003; Kuisma, 2002; Gitlin, 2006a; Gitlin,
2006b). This evidence is particularly strong for fall prevention and activation
programs for the elderly living with long-term conditions such as Chronic
Obstructive Pulmonary Disease (COPD). At present, we have a very limited
understanding of how rehabilitation services are allocated in Ontario. The
purpose of this study is to understand the current process of decision-making for
the allocation of Physical Therapy (PT) and Occupational Therapy (OT) services
using case scenarios of two clients, one with a diagnosis of COPD, the other with
a history of falls.
Literature Review
According to the world confederation for Physical Therapy (2011), Physical
Therapists (PTs) serve individuals and populations to develop, maintain and
restore maximum movement and functional ability throughout the lifespan.
According to the Movement Continuum Theory (Cott et al.,1995), functional
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movement is central to physiotherapy and what it means to be healthy. Similarly
according to the World Confederation of Occupational Therapy (2011)
Occupational Therapists (OTs) promote health and well being through
occupation. The primary goal of OT is to enable people to participate in activities
of everyday life. Occupational therapy achieves this outcome by enhancing the
client’s ability to participate or by modifying the environment to better support
participation.
A scoping review of the current literature was performed to identify patient groups
for whom PT & OT homecare is known to improve client outcomes. A research
librarian was consulted to identify appropriate key words and databases for the
search. The selected key words were: Homecare or Home Care, Physiotherapy
or Physical Therapy and Occupational Therapy. Online databases including
Cochrane, Medline, CINAHL, Pedro, Amed, Embase and Psycinfo were
searched using the selected key words. The search was limited to human
subjects, age: 65 and over, abstract: available online and language: English only.
This search produced 3209 papers. The search was further refined by a title
review to identify the scope of the paper. The abstract was reviewed when the
title did not provide sufficient information about the scope of the paper. Literature
on acute care such as post surgical care, hip fractures and total joint replacement
were excluded from the search. This refinement generated 294 papers that
demonstrated effectiveness of PT or OT or both in the areas of fall prevention,
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Home safety, COPD, CVA, Cancer, Cardiac rehab, Cognitive rehab, tele-rehab,
osteoarthritis and general geriatric rehab for various debilitating conditions.
Amongst these areas of PT and OT effectiveness, a small group of clinical
problems often identified amongst patients seen by homecare case managers
were selected in consultation with experts in the field (CCAC collaborators).
These issues were COPD and Falls prevention. The nomination of these issues
was performed by the investigative team along with a panel of volunteer
collaborators from various CCACs based on their current priorities. In addition,
literature on the history of homecare in Ontario was reviewed in order to
understand the evolution of the current system for allocating PT and OT services
in Ontario CCACs.
Falls Prevention
About 30% of community dwellers over 65 years of age fall each year (Tinetti,
Speechley & Ginter, 1988). Fall-related fractures or traumas are considered the
main sources of morbidity for the elderly (Tinetti & Williams, 1997). The major
psychological effect of falls is fear of falling which causes a significant reduction
in self-confidence and social interaction (Vellas, Wayne, Romero, Baumgartner,
& Garry, 1997). Falls are also an independent predictor of nursing home
admission (Tinetti & Williams, 1997).
4
Moreover, falls impose a huge economic strain on the health care system.
According to the World Health Organization (WHO) a fall is defined as an event
which results in a person coming to rest inadvertently on the ground or floor or
other lower level. Falls were responsible for 15.5 per 1000 hospitalizations
among seniors from 2008 to 2009 in Canada (Scott, Wagar & Elliott, 2010). The
average length of stay in hospital for a fall-related injury was 15.1 days, which is
70% longer than the length of stay for other causes of hospitalization (8.9 days)
(Scott et al., 2010).
Falls are the major cause of hip fractures among the elderly. According to the
Ontario Injury Prevention Resource Center (2008) falls are the cause of one half
of the deaths caused by injury among the elderly population and this number is
greater than the deaths due to diabetes and pneumonia. Scott et al. (2010)
found that among Canadians aged 65+, 51% of the falls resulting in
hospitalization occurred in or around home and 18% of the falls occurred in
residential care facilities.
One of the devastating effects of falls is a decrease in independence. Thirty-five
percent (N=18,800) of Canadian seniors with a fall-related hospitalization from
2008 to 2009 were discharged to continuing care facilities. In Canada, falls cost
$2 billion annually, an average of $500 per senior. By 2031, it is projected that
older adults will make up 24% of Canada’s entire population and approximately
$4.4 billion will be spent on direct health care costs for fall-related injuries among
5
this age population (SmartRisk, 2010). Thus the reduction and prevention of falls
should be considered a priority for the Canadian health care system.
A large number of randomized clinical controlled trials have investigated the
efficacy of numerous in-home fall prevention strategies for the elderly. Some of
the most promising studies include exercise programs, either separately or as an
important component of a multicomponent program. One of the risk factors for
falls among the elderly is physical deconditioning, resulting in low muscle
strength, decreased balance, impaired gait and mobility, all of which can be
treated with appropriate exercise interventions (Gillespie et al., 2009).
“The effect of exercise programs in reducing the risk and rate of falling should
now be regarded as established,” state Gillespie and colleagues (2009, p. 27) as
a part of their Cochrane review. This review, which examined the evidence for
the effectiveness of fall prevention interventions for older adults living in the
community, included 111 randomized control trials (RCTs) published by June
2008 with a total of 55,303 participants. One key finding was that individually
prescribed exercise carried out at home reduces both the rate of falls and risk of
falling.
In a systematic review of exercise for reducing the risk of falls among community
dwelling elderly persons, Arnold, Sran, & Harrison (2008) found that both
individual and group exercise programs reduced falls. According Barnett, Smith,
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Lord, Williams, & Baumand (2003), weekly group exercise programs were found
to reduce the rate of falling amongst at-risk community dwelling elderly. Exercise
sessions lasting 45 minutes, including warm up and cool down for 8 weeks,
reduced the risk of falls among elderly people who had been recently
hospitalized, had been on bed rest or had low levels of physical functioning
(Morgan, Virnig, Duque, Abdel-Moty & Devito, 2004).
Chronic Obstructive Pulmonary Disease (COPD)
According to a report published by the Canadian Thoracic Society (2003),
mortality and morbidity from Chronic Obstructive Pulmonary Disease (COPD) is
increasing, as is its resulting economic burden. The increases are more
prominent among older adults aged 65 and over. Due to frequent, progressive
and insidious exacerbations, older adults with COPD tend to require formal and
expensive care. In 1998, care for older adults with COPD in Canada cost about
1.67 billion, including hospital stays, long term disability, short term disability and
drugs but excluding the physician and community care. The high rates of
hospitalization among people with COPD (the seventh most common cause of
hospitalization for men and eighth most common cause for women) and re-
hospitalization (40% for both sexes) were the main reasons for these high costs.
The typical history of a COPD patient is progression of disability and death due to
respiratory failure (Burrows, Bloom & Traver, 1987). These manifestations are
preventable through active lifestyles, exercise programs, energy conservation
7
practices and various other rehabilitative techniques. A Cochrane review by
Lacasse, Goldstein, Lasserson and Martin (2006), concluded that rehabilitation
including PT and OT can significantly reduce fatigue, dyspnea, and improve
emotional function and overall functional capacity among COPD patients. This
systematic review, which included thirty-one RCTs, recommended an exercise
regime for at least four weeks as an essential component of the management of
COPD. However a national survey conducted in 1999 indicated that only 2% of
COPD patients in Canada have access to such a rehabilitation program (Brooks,
Lacasse & Goldstein, 1999).
A Cochrane review by Ashworth, Chad, Harrison, Reeder and Marshall (2005)
established high-level evidence that both home-based and center-based exercise
programs improve health and wellbeing of older adults living in the community.
The objective of this review was to discover whether an exercise program at
home or in hospital is better at improving health for older adults. The review
included six studies with over 370 patients who were at least 50 years old and
had a diagnosis of COPD or heart disease. The review compared clients who
performed exercise programs at home with those who exercised in a hospital or
other health care facility. The findings suggest that clients tend to be more
compliant with home programs than center-based rehabilitation. Improved activity
tolerance, reduced blood pressure and improved physical functioning achieved
through home-based programs were also better maintained following home-
based programs.
8
An RCT by Boxall, Barclay, Sayers, and Caplan (2005) assessed the
effectiveness of a twelve week home based pulmonary rehabilitation program for
60 home-bound COPD clients older than 60 years. The intervention group
received personalized upper extremity exercise programs, walking and
multidisciplinary education sessions on the management of COPD. The
outcomes were evaluated using the 6-minute walk test (6MWT), St. George
respiratory questionnaire (SRQ), Borg Score of perceived exertion, rate of
hospital admission with COPD exacerbation and average length of stay at
readmission. The intervention group improved significantly in the 6MWT, Borg
Score, and the SRQ. At six-month follow-up, the intervention group also had a
shorter average length of stay during hospital readmissions. This study
recommended a 12-week home-based pulmonary rehabilitation program to
improve exercise tolerance, breathlessness and quality of life for homebound
clients with COPD.
Another RCT conducted by Strijbos, Postma, Van Altena, Gimeno and Koter
(1996) concluded that a home-based exercise program was feasible and
effective for clients with moderate to severe COPD to increase their activity
levels. This study measured the physical functioning of 41 clients with COPD
randomized to in-home rehabilitation or control group. The primary outcome
measures used in this study were the four-minute walk test and Cycle ergometer
test at 3, 6, 9, 12 and 18 month follow up. Walking distance increased
9
significantly in the home program group; this improvement was retained up to 18
months.
Similar results are demonstrated by several other studies. Du Moulin, Taube,
Wegscheider, Behnke, and Van Den Bussche (2009) demonstrated the
effectiveness of a home-based maintenance program followed by an out patient
program. Ferrari and Colleagues (2004) demonstrated similar results for
moderate COPD Clients with an “inexpensive” exercise program such as a
Stationary Bike for 12 weeks. Therefore the feasibility and effectiveness of home-
based rehabilitation for a COPD client is well documented in the literature.
In summary, there is strong evidence for the effectiveness of rehabilitation
homecare interventions for elderly persons at risk of falls and for persons with
COPD.
Rehabilitation Services in Ontario Homecare
Homecare was identified as the next health care service that should be
considered essential in Canada (Romanow, 2002), but there is still no national
standard for home care programs. Currently, home care services vary greatly
across the country (Coyte & McKeever, 2001), and even within provinces.
In Ontario, the history of publicly funded home care services can be traced back
to the late 1950s. This history has been “characterized by “piecemeal growth”
10
and variations in services available across the province leading to considerable
inequities in access to care” (Randall & Williams, 2006, p. 1597). In 1958 the
government of Ontario initiated a pilot homecare program that only served acute
patients. The objective of this program was to reduce pressure from the hospitals
by reducing their length of stay. The popularity and feasibility of the program led
to its province wide implementation in 1972 (Williams, 1996). The success of this
program seeded plans for various other programs such as chronic homecare
programs, School health support services and Placement coordination services.
The chronic homecare program was initiated in 1975 and was rolled out as a
province wide service by 1980s (Baranek, 2000).
The placement coordination service was created and evolved between 1979 and
1994. This particular service was initiated to support the various needs of seniors
looking for long-term care. By 1994 this program not only provided placement
services but also acted as an information source on various other long-term
community based programs. The examples of such community-based programs
include present day Meals on Wheels or Adult day programs (Williams, 1996).
By the early 1990s, Ontario had 38 homecare programs governed by various
authorities. The majority of these programs were operated by local hospitals and
municipalities but the services were contracted out to external provider agencies.
The heterogeneity in governing structures was the root of regional variation in
service delivery. There were no benchmarks for the rate of services or quality
11
indicators across different jurisdictions. Several attempts were made by the
government to solve the inequity in service delivery and control the rising cost of
homecare (Baranek, 2000). The government was looking for a model of care that
would integrate all long-term care services and provide a single point of access
to the public. The mature version of this vision is the Long Term Care Act, 1994.
This legislation aggregated all the existing homecare and long term care services
into a single program with multiple components namely: community support,
personal support, home making and professional services. In its original version,
this act restricted the use of “for profit organizations” as service providers. With
the challenge of rising service costs, increasing demand for in home care and
growing numbers of commercial for profit provider agencies, the government
introduced Community Care Access Centers (CCACs) in 1996. CCACs took over
existing homecare and long term care services and implemented a new model of
service delivery called “managed competition”. This model allows direct
competition between nonprofit and for profit agencies in order to ensure “the
highest quality at the best price” (Williams, Barnsley, Leggat, Deber & Baranek,
1999). Under the managed competition model, it was claimed that a separation
of purchaser and provider was necessary in order to create incentive for
efficiency in service delivery. The government argued that the full competition
would be compromised if access centers provide service directly (Ontario
Ministry of health, 1996).
12
Prior to the implementation of managed competition, homecare programs in
Ontario already had significant separation between purchaser and provider. This
was because the majority of the nursing and personal support services were
already contracted out to external agencies such as St. Elizabeth’s Nursing and
the Red Cross. However the majority of the rehabilitation services provided
through homecare were operated directly by the homecare programs. Hence with
the introduction of managed competition, CCACs were expected to divest their
frontline rehabilitation professionals to external providers. This process of
“divestment” entails that the CCACs transfer their rehabilitation staff to external
agencies and from which they then received services on a contract basis. This
process was supposed to take place between the year 1997 and 2000 (Randall &
Williams, 2006).
At the beginning, CCACs were independent from the government. There were
guidelines from the government but CCACs were self-managing based on local
needs for services. This raised the possibility of inequity across the province.
Different clients received different volumes of service based on their location in
the province. To enforce standardization in service delivery and gain managerial
control over CCAC services, the government introduced Bill 130 in 2001. This
legislation provided the provincial government with complete authority over the
CCACs (Randall & Williams, 2006). At the same time the government also
identified a need for a standardized health information system to promote and
monitor system wide quality, efficiency and outcome. In 2002 the MOHLTC
13
mandated the RAI Homecare (RAI-HC) Assessment instrument for use with
CCAC clients who are anticipated to be long stay (more then six months).
RAI-HC is a comprehensive assessment and problem identification system
developed by an international network of more than 30 researchers from 18
countries. The network, known as interRAI, is a not-for-profit research consortium
with members from North America, Nordic countries, Western Europe, Czech
Republic and the Pacific Rim (www.interrai.org). The primary purpose of the
assessment is to focus on clients’ needs. Items or combinations of items in the
assessment identify problem areas for service planning. These combinations of
items are in form of algorithms and called Clinical Assessment Protocols (CAPs).
The purpose of the CAPS are to guide care and service planning but case
managers are not obliged to use the CAPs in determining service use. An
example of a CAP is falls CAP which is triggered by a recent history of falls, gait
disturbance, postural hypotension, fear of falling or psychotropic drug use. If any
of these characteristics are present, the home care team is encouraged to
complete a more detailed assessment related to falls and plan care if needed to
reduce the risk of falls (Hirdes et al., 1999).
In 2006, the Ontario Government changed the way health care services are
planned, funded and managed by implementing Local Health Integration
Networks (LHINs). LHINs were created to promote more patient focused, result
driven, integrated and sustainable system. Following the establishment of the
14
LHINs, the government of Ontario decided to realign the 42 existing CCACs to
create 14 CCACs with the same geographical boundaries as the 14 LHINs.
Currently all CCACs are funded and legislated by the Ontario Ministry of Health
and Long-Term Care (MOHLTC) and sign accountability agreements with the
corresponding LHINs. They represent a single point of entry to long term care
(LTC), homecare, and other community services. Case managers from the
CCACs are responsible for assessing and developing service plans for homecare
clients. Service provider agencies that include rehabilitation services bid for
contracts with each CCAC separately.
This system of service delivery based on managed competition has been
criticized for compromising the quality of care provided in clients’ home (Cott,
Falter, Gignac & Badley, 2008; Aronsen, 2006; Aronsen & Neysmith, 1996). This
is primarily due to the fact that the system is based on cost-effectiveness rather
than client centeredness. Case managers are the gatekeepers for all the
homecare services and their process of decision making revolves around
financial constraints (Cott, Falter, Gignac & Badley, 2008).
In addition to quality of care, the managed competition model also has
implications for the health care professionals working in the community. Ceci
(2006a) concluded that case managers and homecare professionals are
frustrated due to their inability to meet their clients’ needs. The author argued
that homecare is seen as a business concept where various administrative
15
solutions have been applied to ensure cost control instead of quality control. As a
result homecare workers are forced to provide care in a cost effective manner
rather than focusing on client need and maintaining the highest quality of care.
These economic forces are creating frustration amongst the homecare workers
and compromising job satisfaction in the field of homecare.
Aronsen and Neysmith (1996) identified similar frustrations amongst personal
support workers employed by homecare providers. They concluded that the
tension caused by financial constraint reduced home care workers' ability to
deliver high quality care. Their intension to provide client centered care is
compromised by organizational practices that speed up and intensify their work
Finally Cott, Falter, Gignac and Badley (2008) stated that the CCAC model of
service provision is creating competitions, exacerbating role-boundary tensions
and discouraging communications amongst homecare providers. The
combinations of these effects are counterproductive in terms of the quality of
care provided in clients’ home.
Various other studies have also sited similar findings in terms of the negative
implication of the CCAC model of service provision (Denton, Zeytinoglu, &
Davies, 2002; Neysmith & Aronson, 1996). Hence there is extensive evidence to
establish that the current model of CCAC service provision has negative
implications on client and homecare workers. However an investigation of how
16
decisions are made, whether to provide homecare services or not, particularly
rehabilitation services is yet to be done.
Regional Variations in Therapy Services Allocation
The implications of managed competition and CCAC model of services provision
produced a shortage of services in homecare, particularly for the therapy (PT &
OT) services. Despite recent evidence that home-based rehabilitation can
improve functional outcomes, older patients do not always receive the
appropriate rehabilitation services. For example, Hirdes and colleagues (2004)
found that 71.2% of older homecare clients assessed as having rehabilitation
potential did not receive any type of rehabilitation. Some of the contextual factors
behind this lack of service are hypothesized to be a lack of knowledge among
case managers of the demonstrated benefits of rehabilitation, organizational
values of serving medical needs as opposed to rehabilitation needs, inefficiency
in the delivery of care and constraints of the health care system (Gitlin et al.,
2006a). The optimal situation would be to generate rehabilitation referrals based
on the functional and clinical characteristics of clients that suggest a need for
services. However regional variations (Appendix 1: Figure 3, p. 84) suggest that
client characteristics may not be the only factors influencing rehabilitation referral
by CCAC case managers, since patients with similar clinical characteristics are
not getting same volume of service across different CCACs. Other factors
apparently are influencing rehabilitation referral decision making.
17
Egan and colleagues (2009) explored information needs of case managers to
plan care for post hip fracture patients. In this study, the question of referral to
rehabilitation professionals was not explored, as standard practices for hip
fracture patients (e.g., care paths) used by these case managers generally
included homecare rehabilitation. This may not be the case for long-term
conditions such as COPD, where patients are medically complex and have
multiple co-morbidities (Wells, Seabrook, Stolee, Borrie & Knoefel, 2003). The
case manager decision making-process may be quite different for acute and long
term patients; this issue has not yet been explored.
Hirdes and colleagues (2006) have examined the distribution of PT and OT
services within the context of a larger Primary Health Care Transition Fund
(PHCTF) study. This study stimulated the development of the interRAI Contact
Assessment (RAI-CA) which forms the core of the Common Intake Assessment
Tool (CIAT) and which guides the triage of homecare referrals. Within the RAI-
CA, three algorithms are embedded that include an algorithm to identify those in
need of a full RAI-HC assessment, an urgency algorithm, and a rehabilitation (PT
& OT) algorithm. An analysis performed on RAI-HC data linked with Ontario
Home Care Administrative System (OHCAS) claims data showed variation in the
proportion of clients who received any PT or OT across different CCACs
(Appendix 1, Figure 3). Regional variation was still great even within the highest
categories of rehabilitation referrals (i.e. those most likely to need and benefit
from rehabilitation according to RAI-CA rehab urgency algorithm) (Appendix 1,
18
Figure 4, p. 84) The factor that appears strongly related to the receipt of
rehabilitation services was whether an individual was referred to homecare from
an acute care setting. Recently hospitalized patients were much more likely to
receive rehabilitation across all priority levels for rehabilitation.
The Contact Assessment, which contains the rehabilitation (Appendix 1: Figure
5, p. 85) and two other algorithms, is being rolled out gradually to all regions of
Ontario. The Contact Assessment will provide results for the three algorithms but
case managers should be able to use their judgment on whether or not to refer to
rehabilitation services. It would be useful to have a better understanding of
current practice decisions prior to the full implementation of the contact
assessment and the associated imbedded algorithms, recognizing that decisions
made by case managers may be influenced by shortages (or perceived
shortages) of therapists in their area, lack of other resources, administrative
policies, or MOHLTC/LHIN directives.
The question of how case managers in Ontario decide to whom homecare
rehabilitation services (e.g. physical therapy and occupational therapy) should be
allocated, particularly amongst long-term clients or those whose diagnoses are
not typically associated with a care path that includes rehabilitation, has not yet
been determined. The rehabilitation algorithm generated from the Contact
Assessment is based on functional limitations and a recent decline in function
rather than diagnosis; this algorithm could become a key decision making
19
support for the long stay clients primarily based on client need. On the other
hand, factors other than client need may influence the decision to refer to
rehabilitation. It is important to understand such factors and to determine whether
they are consistent with the best available evidence. The objective of this study
is to explore the process of decision-making for the allocation of PT and OT
services for the long stay clients in Ontario homecare:
1. How do homecare decision makers describe their process of
decision making?
2. Do homecare decision makers in Ontario share a common rationale
for referring to PT and OT services in response to client vignettes?
3. Do homecare decision makers in Ontario value aggregate data
analyses in formulating their decision for allocating PT and OT
services?
20
Chapter 2: Methodology
This chapter provides a description of the research design, methodology and
rationale for making various methodological decisions. Issues of confidentiality
and ethics are also discussed.
Design
The nature of these exploratory questions suggests a study using qualitative
methods. Therefore the study centered on key informant interviews with case
managers and administrators from CCACs across the province. A sample of four
CCACs was selected based on high and low user of rehabilitation services (PT
and OT) in urban and rural settings (Appendix1, Table 1, p. 79). Interviews
included open ended and semi-structured questions regarding vignettes and
analysis of RAI-HC data holdings (Appendix 3: The Interview Guide, p. 93). An
advisory committee consisting of three CCAC decision makers (two case
managers and a client service manager) was formed to act as decision making
partners to the researchers throughout the research process. The advisory
committee members volunteered to participate in the study in response to a
written request submitted to each of the participating CCAC for their
collaboration. Their insights were used to develop the interview guide and to
recruit participants.
21
The participants were provided with both a summary of the study describing their
role and consent form at least a week before the interview. Participants signed
the consent form before proceeding to the interview. Demographic information
about the participants, including professional designation and years of
experience in homecare, was collected at the end of the interview.
Phase 1: Development Phase
The Interview Guide
A semi-structured interview guide was developed based on the findings from the
literature review, informal discussions with the advisory committee members, the
rehabilitation algorithm from the contact assessment (Appendix 1: Figure 5, p.
85) and RAI-HC data analysis (Appendix 3: The Interview Guide, p. 93).
Rehab algorithm of the contact assessment: The rehabilitation algorithm
embedded in the contact assessment (Appendix 1: Figure 5, p. 85) was used to
generate the skeleton of the vignettes. The functional characteristics of the
patient described in Vignette A are consistent with priority level 1 (Very High
Priority) according to the contact assessment algorithm. The patient described in
Vignette B was designed to be consistent with level 3 (Moderate Priority). The
final version of Vignette A and B were developed following the literature review
and informal discussion with CCAC case managers and administrators.
22
Informal Discussion: Factors influencing case manager’s decision making such
as living arrangements, burden of care and co-morbidities associated with each
of the vignettes were generated through informal discussions with CCAC
partners and the investigative team. An education specialist for RAI-HC was
consulted to determine appropriate scores of various outcome measures
embedded in RAI-HC. These discussions were primarily done via
teleconferences, with the exception of a few face to face interviews.
The Vignettes
A combination of the advisors’ insights, investigators’ experience, rehab
algorithm and academic knowledge was used to construct RAI-HC 2.0
assessments for vignette A & B representing typical home care clients. Vignettes
were adapted to represent a typical client with COPD and a typical client at risk
of falling. Personalized Health Profiles (PHP) gathered from the constructed RAI-
HC 2.0 assessments were used in the vignettes described to the case managers
and administrators during the interviews (Appendix 3: The Interview Guide, p.
93). Questions associated with each vignette consisted of open ended and
structured questions devised to explore decision-making regarding the provision
of rehabilitation services and associated contextual factors.
23
Data Charts
Upon request, analysts from the University of Waterloo compared outcomes of
home care clients who were and were not referred to therapy. Outcomes of
interest were:
1. The rate of discharge from homecare with service plan completed within
six months (Appendix 1: Figure 1, p. 83)
2. The rate of admission to LTC (Appendix 1: Figure 2, p. 83)
Data sources were the 2006-2008 Ontario provincial home care data holdings
containing RAI-HC assessments linked to Home Care Database (HCD) that
records admission information, service utilization and discharge information of
the homecare clients. These analyses are strictly bi-variant and unadjusted for
other factors. The results were tabulated into a bar graph. These figures were
used as an example of aggregate data analysis to stimulate discussion during
the interviews and explore participants’ potential use of outcome research in their
decision making.
Finalizing the interview guide: The final form of the interview guide consisted
of three segments. The first segment consisted of open-ended questions to
explore the process of decision-making. The second segment included semi-
structured questions focused on the vignettes. The final segment consisted of
semi-structured questions referring to the data chart produced from the analysis
of the RAI-HC data holdings. The interview questions used for the case
24
managers were phrased differently from those for the administrators due to their
management role in CCACs (Appendix 3: The Interview Guide, p. 93).
The interview guide was pretested with a graduate student to ensure clarity of the
questions. The interview guide was also pretested on two case managers from
different CCACs to ensure its relevance and clarity. Necessary adjustments were
made to ensure authenticity of the vignettes. Finally the revised interview guide
was reviewed and validated by the entire investigative team and CCAC partners
before proceeding to Phase 2, the interview phase.
Phase 2: The Interview Phase
Sampling: To reflect a variety of perspectives and contexts, 10 case managers
(2 – 3 per CCAC) and 4 administrators (1 per CCAC) from four CCACs across
Ontario were interviewed. The four CCACs were chosen to represent high and
low volume of referrals to rehabilitation service providers in urban and rural
settings.
Analysts from the RAI collaborating center at Waterloo were consulted for the
selection of the sample CCACs. Data sources were the 2006-2008 Ontario
provincial home care data holdings containing RAI-HC assessments linked to
Home Care Database (HCD) that records admission information, service
utilization and discharge information of the homecare clients. Based on the RAI-
HC assessments performed between April 2006 and March 2008, a Logistic
25
regression analysis has been performed on PT or OT visits in both urban and
rural setting. Urban and rural is identified by the postal code of the client. The
mean proportion of PT or OT visit in urban settings is 0.339 (Appendix 1: Table 1,
p. 79). The mean in rural setting is 0.269. Two CCACs bellow average and two
above average were sampled for this study (one rural and one urban in each
category). A profile of the sample CCACs is provided in Table 1.
Table 1: Profile of the sample CCACs Sample Location Rehab Use CCAC Code Name CCAC 6 Rural High RH (Rural High) CCAC 10 Rural Low RL (Rural Low) CCAC 13 Urban Low UL (Urban Low) CCAC 14 Urban High UH (Urban High)
A written invitation to participate in the study was sent to each of the sampled
CCACs. All sampled CCACs showed interest by providing their letter of support.
One CCAC requested submission to their own research ethics board in addition
to the U of T Research Ethics Board (REB); the rest did not have any REB of
their own and agreed to accept the recommendations of the U of T REB. The
study therefore complied with approval from U of T health science REB (Protocol
Reference # 25699) and one of the participating CCACs.
Recruitment: The CCAC collaborator providing the Letter of Support for this
study was requested to forward an invitation to participate via email to all the
case managers and administrators working for the CCACs in the sample. The
invitation email included the letter of introduction and contact information of the
student researcher and his faculty supervisors (Appendix 3: Letter of
26
Introduction, p. 89). Invited participants were asked to contact the student
researcher or supervisors to indicate their interest in participation. The student
researcher scheduled interviews with the interested participants at their
convenience.
Extreme or deviant sampling was used to reflect a variety of perspectives and
ensure a healthy sample size. At the end of each interview, participants were
asked to identify a few of their colleagues who have had similar and different
experiences. The interviewees were requested to forward an invitation to the
identified individuals, including the letter of introduction and contact information of
the student researcher. Interested participants were requested to contact the
student researcher for more information or enrolment into the study.
In total 10 case managers and four administrators participated in this study. Their
average experience in CCAC was 11.2 years. The pool of participants included
five registered nurses, five social workers, three PTs and One OT. Their average
experience in their profession was 22.5 years.
Case Manager Interview: Case managers were purposefully sampled (Patton,
2002). Inclusion criteria were experience of one year or more coordinating care
for complex long stay clients (e.g. individuals with COPD). Efforts were made to
include case managers with a variety of professional backgrounds (PT, OT, RN,
SW, RD) and years of experience in homecare. Case managers were individually
27
interviewed via telephone in a private office in the Department of Physical
Therapy at the University of Toronto. Interviews were set at the convenience of
the participants. The letter of introduction and the consent form was emailed prior
to the interviews. All other interview tools including vignettes (PHP and RAI-HC
2.0 for A and B), Data Charts (Appendix 1: Figure 1&2, p. 83) and Demographic
profile were sent via email during the interview to avoid pre-constructed
response. The letter of introduction and the consent form were thoroughly
reviewed with participants before proceeding to the interview. The participants
were requested to fax the consent form along with their demographic profile
using a secure fax line at the Graduate Department of Rehabilitation Science
(GDRS). These forms were placed in a locked cabinet behind a locked door in
the research lab supervised by the principal investigators.
The interview had three sections (Appendix 3: the interview guide, p. 93). In the
first section of the interview, participants were asked open-ended questions on
their rationale for referral to PT or OT. In the second section they were asked
semi-structured questions related to vignettes to gather all the implicit and explicit
strategies of decision making for the allocation of rehabilitation services. They
were encouraged to use all of their usual tools (e.g., RAI data, screening tool,
priority guidelines etc.) while working with the vignettes to replicate a real time
case management scenario. The final section of the interview involved
presentation of the Data Chart based on actual client outcomes. The
28
interviewees were asked as to whether the findings described in the chart would
alter or reinforce their decision to refer.
Administrator Interview: In addition to the aforementioned case manager
interviews, key informant interviews were conducted via telephone with senior
managers, administrators, and policy makers from each of the participating
CCACs. They were either in the capacity of a Client Services Director of Client
Services Manager currently employed by one of the sample CCACs. These
interviews were similar in structure (using open ended questions, vignettes and
data charts) with different questions (Appendix 3: the interview guide, p. 93). The
interviews were designed to elicit the administrators’ policies on rehabilitation
services allocations across their CCAC, by gathering their insights regarding
referral to rehabilitation services.
29
Phase 3: Data Analysis
Analytic Framework
The study aimed to explore the process of decision making within CCACs. The
results were expected to be policy oriented and practice related. Two different
analytic strategies were considered: grounded theory and framework analysis.
While analysis using a grounded theory approach may generate policy-relevant
findings and enrich our understanding of health service use, the aim of policy
development is not the objective of a grounded theory approach (Green &
Thorogood, 2009). On the other hand, Framework analysis is explicitly geared
towards generating policy and practice oriented findings. It is a content analysis,
which “involves summarizing and classifying data within a thematic framework”
(Green & Thorogood, 2009 p 208). The primary difference between a framework
analysis and a grounded theory approach is that the integrity of each individual
respondent’s account is preserved throughout the analysis in contrast to “the
deliberate attempt to fracture the data” in order to open up new avenues in
grounded theory (Green & Thorogood, 2009 p 208). Due to the structured nature
and policy oriented themes of the interviews conducted for this study, the
framework approach (Green & Thorogood, 2009 p 208) was adopted to analyze
the interview data. This analytic approach uses four stages, namely
familiarization, thematic coding, indexing and charting, to analyze qualitative
data. In addition, a content analysis of the decision support tools gathered from
each of the CCACs was performed to complement the data collected through
30
interviews. The aim of the content analysis was to classify text into categories
that contains data with similar themes and contents (Creswell, 1998).
Familiarization: This stage involved listening to each of the interview tapes and
re-reading interview transcripts to become familiar with the data (Green &
Thorogood, 2009 p 209). A face sheet was created in this stage to capture
distraction, sarcasm and external effects during the interviews.
Thematic analysis: Analysis of the interviews explored the process of decision-
making and factors that may explain regional variation in the use of rehabilitation
services. The analysis identified themes and commonalities in responses. The
interviewer and one of the investigators with extensive experience in qualitative
analysis independently coded each interview transcript. All the discrepancies
were solved through weekly discussions between the two coders. A codebook
was established based on four transcripts (Appendix 2: The Code Book, p. 86).
Independent codes from each of the reviewers were collapsed into a common
coding scheme to be used on all the transcripts. Inter-rater reliability of the
codebook was established by implementing the common coding scheme on five
randomly chosen interviews. The codebook was further refined based on the
investigators discussion after the establishment of the inter-rater reliability
(Creswell, 1998). Three qualitative researchers (one interviewer and two
investigators) within the investigative team led the analysis of codes and
31
categories of data and all investigators were engaged in the development of
themes arising from the data.
Indexing: In framework analysis, the thematic coding of the data is called
indexing (Green & Thorogood, 2009 p 209). Indexing was done to all 14
interviews based on the codebook.
Charting: Charting involves rearranging the data according to the thematic
content, either by the interviews or by the themes (Green & Thorogood, 2009 p
208). For the purpose of this study, charting was done to perform comparisons
across CCACs and within CCACs by the demographic characteristics of the
participants. Each CCAC is color coded in the following order to facilitate cross
comparison: CCAC Code Name (Table 1): RL =Green, UH= Pink, RH = Yellow
and UL = Blue.
32
Chapter 3: Findings
This chapter reports on the results of the interviews and the content of the CCAC
guidelines gathered from the participating CCACs. The guidelines were collected
after the completion of the interviews. However in order to enhance
understanding of the readers, the content of the guidelines are presented before
the interview results.
CCAC Guidelines:
The study gathered three types of documents from the sample CCACs: a priority
coding tool, therapy benchmarks, service pathways and administrative statistics.
The priority coding tool is used by three of the four participating CCAC. This
tool prioritizes clients based on their functional status, medical needs (acute
versus chronic), recent hospitalization, safety concerns and caregiver burden.
Among these characteristics, caregiver distress, emergent medical needs and
safety concerns receive the highest priority (Priority A) and indicate clients
entitled for rehab services within 24 hours. However the priority rating does not
specify the frequency or volume of services. Patients with long standing chronic
conditions are coded as the lowest priority and recommended for rehab service
within 21 calendar days. Any acute exacerbation of a chronic condition (i.e.
COPD requiring trachea-bronchial clearance) is coded as a high priority (Priority
B) with services recommended to begin within three calendar days. Gradual or
33
recent decline in functional status of a community-dwelling patient with a chronic
condition receives a moderate priority (Priority C), with receive services within
seven calendar days. To capture the operational impact of this tool, one of the
interviewees said:
Typically a lot of those priority A clients are from hospital . . . Could be
someone who just finished a rehab program but requires their home to be
assessed prior to going home, or just when they get home. So they
typically are the Priority As for OTs or PT. Priority B would be someone
that’s at a high risk of injury or decline. They don’t have adequate supports
in the home. And then you would see the Priority Cs that may be someone
who’s living with some supports but they may need additional support or
assistance with new equipment or they may be at a potential for falls but
they haven’t had any falls yet. So, it’s more of a preventative, but you
know the risk isn’t as great as a B Priority . . . . And then for a D Priority
which I rarely use, it’s probably someone who had a piece of equipment in
the home and they wanted to have a refresher or a training on it . . . or
they have an ongoing chronic condition . . . and just need a reassessed or
an exercise program . . . so there is no imminent risk or danger for that
client.
Therapy benchmarks are used by one of the participating CCACs. This tool was
developed in conjunction with service providers and analysis of the local
homecare data holdings. As Ivan describes:
34
We have a therapy committee . . . that meets quarterly. And together with
them, in partnership, we develop what we call benchmarks. So for
example, somebody with identified need of strengthening . . . will get X
amount of visits during X amount of time. And that’s all based on what the
therapists tell us and on data in terms of running a report that says clients
who require physiotherapy . . . on average require 6 visits over 6 weeks.
After then the therapist[s] have a means of asking for more visits to meet
the goal.
The benchmark indicates an authorized number of visits with in a specific period
of time for a certain reason for referral. The reasons for referrals are primarily
treatment technique based. For instance the referral for chest physiotherapy
entitles six visits in six weeks, the referral for home safety assessment receives
two visits within six weeks. It does not specify any goals or expected outcomes of
the treatment.
A more structured version of therapy benchmarks is called the Service
Pathways or ‘care paths’, which were used by all four CCACs for their acute
clients. Only one of the four CCACs identified care paths for their chronic clients.
Not only do these pathways provide an authorized number of visits with in a
specific time period but also specify goals of service delivery and expected client
outcomes. For instance Table 2 is a sample of one of the occupational therapy
pathways to promote functional independence:
35
Table 2: A Sample Care Path
Number of Visits
1 – 3 Visits with in 28 days
Goals of Service
Treatment 1. Perform functional Assessment of ADL and IADL to
provide recommendation to promote independence 2. Perform home safety assessment to identify equipment
need and risk of fall and provide recommendation to ensure safety
3. Perform mobility assessment and provide recommendations to ensure safety.
Education 1. Client/Caregiver will be knowledgeable about safety
issues in the home and community 2. Client/caregiver will be knowledgeable with respect to
strategies and equipment to maximize independence in ADL and IADL
3. Client/caregiver will be knowledgeable regarding techniques and equipment to promote safety and fall prevention.
Discharge Plan 1. Client/Caregiver will be assisted to purchase appropriate
equipment. 2. Client will be linked with community resource if required 3. Discharge report to be submitted at the end of the
pathway 4. Service provider to submit request for additional visits
under extenuating circumstances if the goals are not met.
Expected Outcomes
1. Client educated on home safety strategies 2. Client assessed for ADL and IADL and recommendations
provided 3. Client assessed for mobility and recommendation
provided 4. Equipment need assessed and recommendation
provided
The development of these tools follows a similar process to the one used in the
development of the therapy benchmarks. As Bob describes:
We have some case management pathways. We probably have 20 of
those. Those were developed in conjunction with service providers to
36
define, for a specific functional area, where rehab intervention would be
beneficial, what would be the goals that we will be looking to achieve
based on a best practice approach.
Finally, administrative statistics have been used by one of the CCACs (UH).
These tools are similar to therapy benchmarks. They provide the average
amount of therapy utilized to achieve a specific service goal (i.e. fall prevention)
in the previous years. According to Shirley:
We have data from the past on . . . how many visits a typical therapist had
used for a particular issue . . . and then we have looked back
retrospectively to see how many visits on average a particular issue
needed.
Administrative statistics are data used for administrative purposes only (i.e.
resource planning). This tool is not used directly by case managers for care
planning. At the time of this study, the CCAC using this tool was financially stable
and had no waiting list for any of its services. As a result, decision support tools
like benchmarks or care paths were not being used for their chronic clients.
Well, interestingly we don’t have a wait list right now for in-home services.
. . . I am in charge of the wait list so I know . . . . We have just eliminated
the whole process like a couple of months ago . . . . Even if it’s a low
priority in terms of risk . . . they’ve [service provider] been typically picking
them up.
37
The process of decision making in CCAC
In order to understand the process of decision making for the allocation of PT
and OT services, homecare decision makers were asked a series of open ended
and semi-structured questions. Their responses indicate that each of the sample
CCACs follows several stages in the process of decision making. These stages
include a process of intake, an assessment by a case manager and if assessed
as indicated, a referral to the service provider, the delivery of the therapy
services, reassessment of the client and discharge from the homecare program.
Figure 1 provides a schematic presentation of this process.
Figure 1: The process of decision making in CCAC
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38
The Intake
Source of Referral
Participants report that CCACs receive referrals to their program from multiple
sources. These sources include physicians, allied health professionals, hospitals,
services providers, families and clients themselves. According to Karen these
sources can include:
We might get a physician’s referral if the client has been to their physician
or to the regional hospital here. And they might have identified some need
for occupational therapy or physiotherapy. Therefore they will send me
what’s called a physician’s referral and at that time I will contact my client,
and/or family whoever’s making the decisions . . . . Then we’ll set up the
services, if they’re in agreement. So that’s one way. The other way is that
sometimes I might have a call directly from caregivers or family members
who might have identified a need for their loved one, falls, equipment
needs, or something to make it easier for them. They would contact me
and then I would set it up . . . . Also sometimes homemaking agencies that
are providing service will contact us and say “We’re really struggling with
turning Mr X, and maybe we could look at some sort of a lift or” . . . . So
we would then explore that option. And I would then put occupational
therapy in to assess the appropriate equipment if necessary.
39
Eligibility for In Home Services
According to the decision makers interviewed for this study not all referred clients
are eligible for homecare services. CCACs are legislated to serve a very specific
population called “homebound” clients. Therefore clients’ outdoor mobility has a
significant impact on the allocation of homecare services. For instance Ivan
states:
I’m not sure if you know, but we’re pretty legislated by the Ministry of
Health. The clients who we would accept in terms of eligibility, would be
the clients that have a real difficulty getting out of their house, or their
apartment . . . or getting out to the community. And we refer to them as
“homebound”.
According to the participants the primary purpose of homecare services is to
address medical necessities. Rehabilitation services are there to ensure safety
and are provided on a short-term basis. This vision of identifying the target
clientele of homecare services is common to all four sample CCACs. Kara, an
administrator of one of the CCACs describes this vision in the following way:
Historically home care and CCAC have not been as rehabilitation focused
. . . . I think it is same in hospitals and in other sectors as well. We are
primarily health \ curative focused, and rehab is seen as an extra. So in
times of financial restraint and concern it’s even harder . . . . I don’t want to
use the word justify - it’s even harder to rationalize rehab services. So it’s
very much from an administrative perspective. The concept of helping
40
individuals to be as independent as possible in their home, sometimes
takes second place to the emergent medical health issues.
Selection of Clients
The vision of addressing necessities for homebound clients is apparent in the
selection of homecare clients. According to Maria, a case manager, there is a
process for selecting CCAC clients:
So first of all we need to look into the criteria, whether or not the client can
access the services as an outpatient . . . because it is one of the criteria
for being admitted to a CCAC.
However, everyone who gets referred to CCAC gets an assessment. If they are
not eligible for CCAC services they may get referred to other volunteer or fee-for-
service community supports. As Bob describes:
Everybody who gets referred to us . . . gets an [intake] assessment . . . So
they’re entitled to an assessment, not necessarily [publicly funded]
services.
Across CCACs, there are two variations of these intake assessments. Among
these, the most rigorous form is the use of a standardized assessment tool. At
the time of this study, one of the four participating CCACs used a standardized
assessment tool for their intake process. Bob describes the function of the tool
as:
It supposed to assign clients to the right case management approach. It
makes sure that they’re getting that initial assessment from the most
41
appropriate case manager. So it’s built on some functional items. It’s built
on reported changes in health status and perception of health status . . . ,
some ADL [Activity of Daily Living] items, some IADL [Instrumental Activity
of Daily Living] items, some caregiver support indicators or indicators of
caregiver burden, instability, frailty and complexity.
This tool has been adopted from the contact assessment, an intake assessment
tool that records essential information needed to indicate urgency of homecare
services, need for rehabilitation services and need for further assessment.
However the adopted version of the contact assessment by this particular CCAC
does not include the rehabilitation algorithm to indicate the need for rehabilitation
services. This modification of the contact assessment indicates the transparency
of CCAC vision of serving clients’ medical needs rather than their rehabilitation
needs. As Bob describes:
It’s built on parts of the Contact Assessment that mirrors clinically complex
need for long-stay service. It’s not built on the need for rehab.
The other variations of the intake process primarily consist of telephone
assessment by the case manager and selecting clients based on CCAC eligibility
guidelines.
Case Manager’s Assessment
Eligible clients have to have an assessment from the case manager before
getting any services from CCAC. There is a wide variation among the processes
used by case managers in their assessments. Some case managers rely on the
42
decision support tools embedded in RAI-HC such as Clinical Assessment
Protocol (CAP) for fall risk, ADL etc to justify their decision. Others rely on clinical
indicators such as mobility, cognition, balance etc. However all of the case
managers reported a preference for evaluating clients at home before making
any decisions. In their home assessments they pay particular attention to the
client’s outdoor mobility. For instance, according to William:
If we get somebody calling from the community saying that they want
physiotherapy for example . . . . Obviously one of our first priorities is to
ask “Can you get out?” to have your physiotherapy outside. And if you’re
not pretty much shut in or there’s no other extenuating circumstance why
you can’t get out to get your physiotherapy. Then we’re just going to tell
you, you have to get your physiotherapy . . . in an outpatient clinic, like
everybody else.
Both the case managers and the administrators interviewed for this study
acknowledged the shortage of outpatient or day programs for rehab in the
community. It was a challenge for the participants to provide service for clients
with no difficulty in outdoor mobility who did not have access to outpatient or day
program in their community. In addition such programs were also guided by strict
eligibility criteria. For instance Bob describes his frustration regarding this issue:
The other thing that definitely impacts is . . . the lack of accessibility to
rehab clinics . . . . or the reduction of outpatient clinics . . . . We have to
get people into day programs to supplement care or . . . provide a
transitional level of care . . . . There’s a requirement to have a need for two
43
or more types of therapies services at day programs. I think that impacts
on decision making. Because it’s harder to get people into those settings.
Referral to Service Provider
The most common reason for participants to make a referral to rehabilitation
services was to ensure safety. It was consistent across all CCACs and among all
case managers. For instance Jodi, a case manager stated:
Our goal . . . is to allow her to remain independent in her own home with
supportive services, but I mean again it would have to be first and
foremost to ensure [home] safety.
However they had numerous other reasons for making a referral to PT or OT
services. These reasons were to improve of physical function, reduce pain,
improve cognition, reduce falls and provide equipment prescription. These
reasons were the basis of defining the extent of safety concern. For instance a
client with multiple difficulties in physical functioning, history falls and impaired
cognition would have a higher safety concern in their home. As Cindy stated:
I mean for myself usually rehab is for . . . someone who has mobility
problem . . . memory issues . . . falls . . . need . . . some sort of equipment
. . . strength is affected, balance could be affected . . . range of motion
could be affected. And all these are [creating] . . . safety . . . issues, in
their home.
44
Furthermore participants also describe their tendency to refer to PT if the client
has difficulty in physical mobility and to OT if the client has equipment need or
cognitive issues. For instance Nathalie stated:
If it’s dealing with equipment . . . e.g. wheelchair or cognition then it’s OT.
If it’s using your two legs and mobilization . . . then it’s PT.
A detail description of the individual participants’ response are provided in
Appendix 1, Table 4, page 82.
Volume of Services
Participants of this study stated that they determined the volume of therapy
services based on either a predetermined approach or a collaborative approach.
The predetermined approach refers to an authorized number of visits within a
certain period of time for certain types of therapy goals. This approach primarily
consists of benchmarks and care paths specific to the CCAC. A description and
analysis of these tools are provided in the content analysis of the CCAC
guideline section. According to Karen this process involves:
The only plan that I come up with is . . . setting up the service . . . . We
have standards of how many visits we can put in . . . and then we write
down what the intervention is to be [and] whether that’s from the
physician’s referral or from family.
The collaborative approach refers to a process of determining the volume of
therapy services based on client input, therapist assessment, and case manager
home visit findings. Usually the case manager begins by authorizing two visits of
45
a therapy service for the therapist’s assessment. The therapist will then provide a
report indicating the amount of services needed to accomplish the client’s goals.
All four CCAC uses this approach to some extent or in combination with the
predetermined approach. The UH CCACs uses a collaborative approach with
administrative statistics from the previous years to validate service providers’
requests. The others rely on the case managers’ insights into the situation. For
instance, Cindy states:
Initially when the referral goes out they’re given two visits over a two
weeks period. And then what happens is that the therapist assesses and
calls us to notify what their expectation of the amount of visits needed . . . .
Now I have a little bit of knowledge about what I’m expecting and sort of
the, the amount of time . . . . that I think is reasonable. So if someone’s
asking for an . . . unreasonable amount then I would question the request.
Table 3 summarizes different approaches used by the participant of this study.
This table includes response from both case managers and administrators.
Although administrators do not make clinical decisions regarding volume of
services, they provide leadership and direction to the case managers in their
daily decision-making. Hence their prospective is valuable.
Table 3: Different approaches to determine the service volume
Participants (Pseudo name) CCAC Code Name Volume Ivan RL Benchmark Karen RL Benchmark Naomi RL Benchmark or collaborative Jodi RL Benchmark Nathalie UH Collaborative
46
Shirley UH Collaborative Joana UH Collaborative Sharon UH Collaborative Kara RH Collaborative Cindy RH Collaborative Patricia RH Collaborative William UL Care Path Maria UL Care Path Bob UL Care path or Collaborative
While there are variations across CCACs, the analysis reveals similar
approaches used by case managers working within the same CCACs. High
users of rehab in both urban and rural regions used a collaborative approach
more than a predetermined approach. Low users tended to use a predetermined
approach to determine therapy volume.
Therapy Process
Once the type of therapy and volume of service is determined, a professional
employed by (or contracted to) the agency goes to the client’s home to provide
therapy services. At this time, the therapy professional assesses the client and
establishes therapy goals if the case manager is using a collaborative approach
to decision making. However in a predetermined approach using benchmark or
care path, the goals would be predetermined. If the goals are not met within the
allotted volume of services, the service provider has to go through a process to
request an increase in service volume.
47
Increasing Therapy Services
The process of increasing visits usually involves reporting back to the case
manager. If the case manager feels that additional service is justified, the
provider will be allotted additional visits (see note above regarding the case
manager’s autonomy). The justification for additional visits is determined with
reference to the administrative statistics from previous years in the case of UH,
or by case manager’s judgment of the situation in the other CCACs. In either
case this extension is usually only for approximately two visits. According to
Karen, the process of negotiating more visits usually involves a telephone call
from the therapist:
I would be talking to my OT or PT . . . but they’re very good at saying to
me that if they had two more visits they could probably . . . see a progress.
But then they would also call me and say; “I’ve been in there six times to
do physio. They refused to do it. They refused to let anybody help them,
so we’re done”.
However for William, a case manager employed by the UL- CCAC this process is
much more formal and requires a written report:
Basically what you can do if they’re on a pathway is that . . . if they reach
the end of the pathway and the therapist feels . . . that intervention still
needs to continue . . . . Then they just send you a report stating that they
would like to do that. And obviously if it’s reasonable, we will just extend
that for another period. But I mean our interventions are fairly . . . short. I
mean they’re never going to be like ongoing . . . [for] months at a time kind
48
of thing. So you might extend them for another two or three visits or
something like that but . . . it wouldn’t be a long extension.
At the time of this study one of the participating CCACs, code name RH (Table 1)
was facing financial challenges. Their process of increasing therapy services
would require authorization from the client services manager. As Patricia states:
However now I . . . we’re in . . . a cost-containment and we have wait lists .
. . . I would have to go through my manager to get approval for any
increase in visits. So right now we are to write out a template and justify
why someone would need additional visits . . . and then the manager
would be the one authorizing the increase. And then I would in turn tell the
therapist if it was authorized or not.
Case Manager’s Reassessment
According to the decision makers all participating CCACs have guidelines for the
reassessment of clients in their home. These guidelines dictate the timeframe for
reassessment based on clients’ conditions (acute vs chronic) and their service
level.
Would I reassess her, yes, routinely it would be about every six months. If
she’s getting a higher level of service it would be every three months.
The in-home reassessment becomes a priority for case managers if the client is
receiving a high volume of personal support services (PSW). For instance
William states:
49
As long as somebody’s got a PSW, I’m always going to have to reassess
them.
The reassessment (in-home) is not a priority if the client is only receiving rehab
services. In this case the majority of the case managers would reassess their
clients via telephone calls and in light of the report from the service provider. For
instance Maria describes:
First of all, I needed to get the reports from the [OT or PT] . . . and if I am
the one already do the RAI-HC, I don’t think I need to do the
reassessment.
Based on the reassessment, the client may continue to receive services from
CCAC, get discharged from CCAC (with community services as needed) or be
placed in an alternate level of care if the client’s need cannot be met at home.
Factors Affecting CCAC Services
Once the process of decision making had been described, participants were
asked to comment on factors other than clients’ need that affects the allocation of
PT and OT services in homecare. Participants highlighted the following factors
that influence the allocation of PT and OT services.
Cost Containment
All participating decision makers identified cost containment as being the single
most important factor affecting PT and OT services. Cost containment refers to a
situation where a certain CCAC is having significant financial difficulty and has to
50
cut back on their services. In this situation, usually CCACs only provide high
priority services and maintain waiting list for lower priority services. According to
Ivan this process entails:
When we are in the midst of cost-containment. Which are fiscal realities
that CCACs face. And, part of that reality is operating with our own
existing budget. And not being able to run deficit. So at the end of March,
we have to make sure that our budget is balanced . . . otherwise there’s a
lot of financial implication and ministry implications. So, if we foresee a
time where we’re not going to be able to continue to provide service to our
existing clients and take on new clients. Then from time to time we do go
into cost-containment. And most CCACs operate in this fashion. A lot of
them are policy driven. No CCAC’s are allowed to carry over budget
money at the end of the year. So it’s difficult to kind of roll over dollars. So
from time to time CCAC’s go into budget constraint. When that happens
the entire system kind of clamps down. So we may start wait listing . . .
therapy clients for example, or homemaking clients. It depends on . . .
what we need to do. And that then is going to influence a coordinator’s
task . . . Because if, if that coordinator knows that the client’s not going to
get the service. Then they may start talking about other resources in the
community . . . you know . . . volunteer groups . . .
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The Ministry Funding Method for CCACs
Several participants reported that at the time of this study CCACs were allocated
funding for one year at a time and at the end of the fiscal year unused resources
would go back to the government. As a result CCACs have no incentive for being
efficient because even if they save resources they are not allowed to keep them
at the end of the year. Allocation of multi-year funding has been acknowledged
as a solution for this inefficiency. For instance Kara, an administrator of one of
the participating CCAC describes:
Having organizations have multi-year funding. So allow us to have . . . two
or three years . . . of funding. And that way if we were able to contain
some cost in year one . . . we could roll that surplus over to year two. But
that doesn’t happen now. Like if we save money . . . Or if we find
efficiencies within our system . . . all that money at the end of March 31st
goes back to the Ministry. So you already have a disincentive . . . built into
your system.
Sharing of Client Information
The participants reported that they never shared the complete client profile with
their service provider, and as a result, a lot of the assessments already done by
the case managers had to be duplicated by the service provider. Improving
sharing and providing training to the service providers on the assessment tools
used by CCACs was identified as a solution for this factor by several participants
of this study. For instance Bob states:
52
I think we need to look at assessment efficiencies . . . . What’s being
duplicated between a case management assessment and a rehab
assessment. And get our [service] providers to start using some of the
assessment information, so that their first visit isn’t being lost in . . .
collecting assessment information that’s already been collected. So they
have to work much more like teams with case managers and within their
own organizations. So better coordination within . . . organizations for
sharing information.
Service Providers’ Model of Service Delivery
Several participants indicated that some of the work provided by OTs and PTs
could be done by less expensive workers. For instance Shirley, a client service
manager states:
For the population of clients . . . the overall budget for rehab is fairly good
if you thought about it from a FTE perspective. Like if everything was in-
house or in one facility. And . . . it makes me ask questions . . . is there
things that you could be doing that would be a more efficient service
delivery model in the community. And so I think . . . you can’t just be
waiting for your funders. And you know I hear skilled OTs in the
community telling me time and time again that the majority of their job is
applying for third party funding and following up on that. A lot of times
that’s what we refer for and it’s just not a great use of rehab dollars . . . .
You could hire an admin support staff . . . to complete paperwork . . . I
53
mean clinicians have to do the assessment, determine appropriateness
and all that good stuff. But you know they [Admin Support] can complete
the paperwork, they can follow up on the customer service type of calls
and your funding agencies. They can move the process along. They could
do the scheduling for follow-up visits . . . work with the equipment vendors
to coordinate final delivery. You don’t need to be paying your highly skilled
professionals for that.
Reaction to Vignettes
This section of the interviews was intended to explore if homecare decision
makers in Ontario share common rationale for referring to PT and OT services in
response to client vignettes. Decision makers were interviewed using two clinical
vignettes (A and B). Vignettes were adapted to represent a typical client with
COPD and a typical client at risk of falling.
Vignette A
Vignette A was modeled to be a very high priority (Level 1) for therapy services
according to the rehab algorithm embedded in the contact assessment
(Appendix1, Figure 5, p. 85). All the decision makers interviewed for this study
rated the client represented in vignette A as the highest priority for rehab services
as well. Table: 2 in Appendix: 1 (page 80) summarizes individual responses from
the participants.
54
Decision for Referral
Out of 14 participants 4 would refer to both PT and OT, five would refer to PT
and five would refer to OT. The majority of the case managers agreed that the
client would benefit from both PT and OT. However case managers at three out
of the four participating CCACs were guided by the policy that they are only
allowed to authorize one rehab services at a time. For instance Nathalie states:
First of all our CCAC does not allow us to make the referral to both
services at the same time. I think that . . . they’re trying to reduce the cost
of services . . . . Because we have to choose . . . . [either] OT or PT will . .
. advise us after their initial assessment . . . whether or not their
counterpart would be an appropriate adjunct . . . . And then we make . . .
the service request . . . based on the professional therapist’s assessment
This particular guideline implies that the case manager has to choose between
PT or OT to go to client’s home and assess the need for the other service. A
typology analysis of Table 2 (page 80) in Appendix 1 suggests that case
managers from rehab backgrounds (PT or OT) may be more inclined to choose
their own profession to go in for the first assessment. On the other hand case
managers from professions other then PT or OT, tend to choose OT for the first
visit (Appendix 1: Table 2, p. 80). For instance William a case manager working
for UL-CCAC states:
We almost never put in two therapies simultaneously . . . . So we’re highly
unlikely to ever have an OT and a PT going in at the same time. So what
I’ll often do is I’ll put in the OT . . . because I’ll have grounds for that and I
55
will ask the OT later during her time there, “do you feel that a physio would
be justified in this case”.
The sample of participants interviewed for this study included three PTs and one
OT. This rather small sample size is not enough to justify a typology in
responses. A larger sample size would be needed to determine whether this
finding could be generalized.
Need for Other Services
Eight of the 14 participants indicated a need for PSW for the client Vignette A.
Three indicated a need for social worker due to her emerging depression and two
indicated a need for meals on wheels due to her difficulty in meal preparation
(Appendix 1: Table 2, p. 80).
Volume of Services:
In determining the volume of services, case managers were consistent with their
CCAC’s guidelines described in table 3.
Reassessment:
Seven out of 14 participants relied on the service provider’s report for their
reassessment for the client in Vignette A. Four of them would reassess in three
to six months depending on the allocation of PSW services and one would
reassess in six months. Several interviewees who were employed as a Director
or Client Service Manager were not comfortable commenting on reassessment
56
due their nonclinical roles in the CCAC. There is a notable similarity in the
timeline and approach to reassessment among the case managers employed by
the same CCACs. (Appendix 1: Table 2, p. 80)
Increasing Therapy Visits
Almost all of the participants (12 out of 14) would increase therapy visits if the
goals were not met. Participants from one of the CCACs indicated the need for
their manager’s approval due to their financial constrains (Appendix 1: Table 2, p.
80).
Vignette B
Vignette B was designed to represent a patient with only moderate priority (Level
3) for therapy services according to the rehab algorithm embedded in the contact
assessment (Appendix1, Figure 5, p. 85). All decision makers interviewed for this
study rated the client represented in vignette B as a lower priority compared to
the client in vignette A.
Decision for Referral
Majority of the participants decided to refer to OT only (7 out of 14) for the client
in Vignette B. Table 3 (page 81) in Appendix 1 summarizes the response to
Vignette B. Unlike Vignette A there are no patterns in the responses in terms of
the case manager’s professional designation and referral for services.
57
Need for Other Services
Two case managers would refer a social worker to due to the client’s depression
in Vignette B. Two other case manager suggested a community service called
friendly visits (Appendix 1: Table 3, p. 81).
Volume of Services
The majority of the participants stated that they would take a collaborative
approach in determining the volume of services. All of them mentioned that the
client may not receive more than two visits of therapy services (more likely to
receive OT than PT) due to her higher level of function then the vignette A.
Reassessment
The process of reassessment followed a similar pattern to vignette A.
Increasing Visit
The process of increasing visits also followed a similar pattern to vignette A
Response to Aggregate Data Analysis
The goal of the final segment of the interviews was to explore if homecare
decision makers in Ontario value aggregate data analysis in formulating their
decisions for allocating PT and OT services. The study used an example of
aggregate data analysis that compared outcomes of homecare clients who were
and were not referred to therapy. Outcomes of interest were the rate of discharge
58
from homecare with service plan completed within six month (Appendix 1: Figure
1, p. 83) and the rate of admission to LTC (Appendix 1: Figure 2, p. 83). Data
sources were the 2006-2008 Ontario provincial home care data holdings
containing RAI-HC assessments linked to Home Care Database (HCD) that
records admission and discharge information of the homecare clients. These
figures were strictly bi-variant and unadjusted for other factors. They were
intended to be examples of figures to stimulate discussions with the participants.
Table 4 summarizes the response received from the participant for Figures 1 and
2.
Table 4: Response to Data Chart
Participants Figure One Figure Two Further Research Need Ivan Not Convincing Not Convincing Cost Effectiveness: Rehab Vs. PSW Karen Confusing Convincing No Insight Naomi Convincing Convincing No Insight Jodi Confusing Convincing Readmission Nathalie Convincing Convincing ER, Readmission Shirley Not Convincing Not Convincing No Insight Joana Convincing Convincing Patient Profile Sharon Confusing Not Convincing Patient Profile Kara Not Convincing Convincing LTC prevention Cindy Confusing Convincing LTC: PT Vs. OT Patricia Confusing Convincing Client profile: Hospital Admission William Convincing Convincing Client profile: LT PSW needs Maria Not Convincing Not Convincing No Insight
Bob Not Convincing Not Convincing Client Profile, ER visits, Hospital Admission
* CCAC Code Name (Table 1): RL =Green, UH= Pink, RH = Yellow and UL = Blue.
Figure 1 was based on an outcome measure called “discharged upon
completion of the service plan within 6 months”. This outcome measure is
compared among CCAC clients who received homecare rehab (PT or OT or
59
Both) and clients who did not receive homecare rehab between 2006 and 2008.
The figure indicated that 17% of the rehab group got discharged compared to 6%
of the “did not receive rehab” group. The majority of the participants found Figure
1 confusing or not convincing (10 out of 14). Since most of the participants in this
study had a long stay case load, their clients tend to stay on their caseloads
much longer then six months and some were never discharged. This is why they
stated they wanted to see the profile of the population (i.e. age, sex, diagnostics
etc) before interpreting the information. For instance Kara, a case manager was
very unsure of how to interpret the data charts to began with and she states:
I just found looking at this . . . especially the first graph is not clear at all.
There is way too many variables that I don’t know where those numbers
came from. And you need to have more information associated with this
table . . . to make it worthwhile for me.
Similarly responses were noted amongst administrators. None of the
administrators were convinced by Figure 1. For instance Ivan states:
Well I don’t know . . . [the analysis] is kind of a stretch I think to be honest .
. . it’s a pretty big assumption.
Figure 2 used the same client groups as the Figure 1 and it indicated that 7% of
the rehab group was admitted to LTC compared to 15% of the “did not received
rehab” group. In comparison to Figure 1, Figure 2, was much more convincing for
9 out of the 14 participants. However it was criticized for not including the profile
of the population. For instance Joana, a case manager states:
60
I like this . . . . It’s a good place . . . to start looking into . . . does rehab
actually buffer against institutionalization. I want to know what the
population looks like. That’s where I’m struggling a bit . . . because this
could be general.
Figure 2 was better received by the administrators as well. However it was
critiqued for not providing convincing evidence that therapy prevented admission
to long term care. For instance Ivan states:
The other interesting thing is that, with or without PT or OT services . . .
are not necessarily deal breakers. So just because you had PT or OT
doesn’t necessarily mean you either need to go to long-term care or don’t
need to go to long term care. Right, so, for example . . . my mother puts
her name on the waiting list two years ago. And all of a sudden, her
number comes up. And she had therapy or didn’t have therapy, it’s really
irrelevant in terms of, going to long term care. It’s not going to make her
say, “I don’t want to go”. And it’s not going to make her say, “yeah I should
go”.
After the participants provided their insight on Figure 1 and Figure 2, they were
asked to indicate their preference for aggregate data analysis or outcome
research to inform various decisions for the allocation of PT and OT services in
homecare. Majority of the case managers were interested for outcome research
involving LTC admission, ER visits, hospital readmission and profiles of the
61
patient populations that could benefit from homecare rehab services. For
instance Nathalie questions:
If they have homecare rehab, is the frequency of ER visits reduced? And
then with rehab in place, does it affect the hospital admissions?
On the other hand administrators were primarily interested on patient profile and
cost effectiveness analysis. For instance Ivan states:
So, who are the clients, and what are their profiles, that we’re able to
make the most gains in terms of . . . prevention of hospitalization or . . .
deferring long-term care . . . or decreasing number of falls . . . . Is there an
ideal client population that we should be targeting?
One of the administrators also provided an example of the type of research that
he likes to see for the cost effectiveness of rehab services:
And what we’ve thought about and we actually did this as a pilot study.
Instead of automatically slapping in a personal support worker for an hour
a week, and make the people dependent on that person . . . Why don’t we
send in an occupational therapist as a first line intervention, and see if
there’s a means of adapting their environment or offering another therapy
like physiotherapy to strengthen them so that we can keep their
independence . . . . We targeted the people that we had waitlisted for
homemaking and personal support. We were able to decrease that waiting
list by 40% by offering that occupational therapy . . . a visit as a kind of
first line intervention. It meant that occupational therapist could go in . . .
take a look around, do their assessment and put in an intervention then
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that doesn’t need a personal support worker. So we actually were able to
remove them from the wait list. So I guess you would like to have some
sort of outcome like that . . . because the last thing we want to do is . . . to
keep people dependent on our system. And it’s very costly as well. So, we
can pay a $110 for an OT visit every week, once a week, that’ll eat up a
month of, of personal support.
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Chapter 4: Discussion
The primary objective of this research was to explore the process of decision
making for the allocation of PT and OT services in homecare. The results
suggest that the clients’ needs are assessed with respect to various contextual
factors (e.g. financial constraints) to formulate decisions for the allocation of
homecare rehabilitation (PT and OT). All four stages of the decision making
process (Figure 1) are influenced by clients’ needs, such as ADL/IADL
restrictions and home safety concerns. However the stages are also heavily
influenced by financial constraints and several system factors such as ministry
funding scheme, information sharing and certain models of service delivery. All
the factors affecting the process of decision making regarding the allocation of
PT and OT services outlined in Figure 2. Since the effect of these contextual
factors varies across the CCACs, the allocation of rehab services also varies
widely across the CCACs (Appendix 1: Figure 1, p 83).
Figure 2: The Decision Making Funnel
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Financial constraint is the most influential element for all stages of decision
making. Its greatest impact is noted on the generation of referral to the service
provider and the overall therapy process. At times of financial constraint (i.e. cost
containment) the referral to therapy services is restricted by various measures
such as wait listing clients and linking to alternate community resources. The
length of therapy is affected by the introduction of various administrative hurdles
on the process of increasing therapy visits. These hurdles include insistence on a
written request to extend therapy and implementation of a two-step decision
making process where therapist must request further visits from the case
manager, who must then present this request to a client services manager, rather
than making the decision independently. Such hurdles may be more important in
discouraging therapist request for further services, rather than ensuring client
needs are met.
This finding that financial concerns are primary considerations in the allocation of
therapy services resonates closely with the findings from Cott et al. (2008);
Aronsen (2006); Ceci (2006a); Denton, Zeytinoglu and Davies (2002) and
Aronsen & Neysmith (1996). All of these studies described the CCAC process of
allocating homecare as a business concept, which is a byproduct of the managed
competition model used by CCACs for their service provision. This method of
service provision encourages the use of administrative solutions to the allocation
of services to assure cost control instead of quality control. Case manager
decisions based on financial challenges are prime examples of this concept.
65
Furthermore decisions regarding the frequency and volume of services,
particularly for CCACs using predetermined approaches (Care Path &
Benchmark) are more managerial than professional (PT or OT). This indicates
that economic forces such as financial constraints rather than client need are
more influential in case manager decision making. As these forces become more
influential, case managers will have limited capacity to utilize the clinical
assessment of their clients in their decisions. This finding also echoes the results
from Ceci (2006a), Cott and Colleagues (2008) and Aronsen (2006) who
described the primary barrier for homecare worker to be client centered is the
pressure of various economic forces in the homecare sector.
The impact of financial constraint is higher on CCAC therapy services than it is
on CCAC medical services. This is due to CCAC’s primary vision of serving the
client’s emergent medical necessities. Ironically, this may limit preventive
approaches in that rehabilitation needs perceived by case managers to be minor
would need to become emergency issues before the patient receives homecare
services. This finding is consistent with Hirdes and colleagues (2004) who
argued that recently hospitalized patients about to be discharged have been
much more likely to receive rehabilitation services than CCAC clients already in
the community, even if the latter were in the highest priority category for
rehabilitation.
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The decision makers’ responses to Vignette A & B suggest that decisions
regarding the service priority for Vignette A & B are consistent with the contact
assessment rehabilitation urgency algorithm. Participants are also consistent in
their rationale of providing rehabilitation services primarily for safety concerns.
However decision makers from three of the four participating CCACs were only
allowed to provide one therapy service at a time (either PT or OT). This particular
guideline forced them to choose either PT or OT services even though the client
has needs for both of those services. Again this finding also indicates that
financial consideration is more important than clients’ need in CCAC model of
service provision and consistent with the findings from Cott and Colleagues
(2008); Aronsen (2006); Ceci (2006a); Denton, Zeytinoglu and Davies (2002) and
Aronsen & Neysmith (1996).
Finally participants’ reflections on the data charts indicate that they require
precise information on the homecare clients whose outcomes are being linked to
rehabilitation services. This requirement is needed for them to be convinced that
rehabilitation is a key factor for achieving better outcomes. They are also
interested in identifying the profile of the clientele who can gain maximum benefit
of the healthcare dollars spent on them. The major outcomes of their interest
included rate of LTC admission, hospital admission, ER visits and profiles of
clientele who can benefit from in-home therapy services. In order to be
convincing these analyses should be controlled for patient characteristics, such
as age, sex, cognition, diagnosis etc. Hence data analysis intended to change
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case managers’ practices should be focused on system-wide potential benefits,
i.e. longer term outcomes related to decreased health service use and delayed
institutionalization that relate to long term cost benefits. Existing databases held
by the Canadian Institute for Health Information (CIHI) and Canadian RAI
Collaborating Centre in Waterloo permit the monitoring of the regional variation of
rehabilitation service use across Ontario using the RAI-HC. Further research is
needed to explore these opportunities and examine the effect of monitoring
outcomes of homecare rehabilitation and present them back to the front line staff.
Limitations
All interviews were conducted via telephone. Hence the interviewer was blinded
to the informal communication of the participant (Creswell, 1998). A face sheet
was created to record all informal communication during interviews to minimize
this limitation. Despite this limitation, a telephone interview is convenient and has
advantages when the researcher does not have direct access to the participants
(Creswell, 1998). The majority of the participants recruited for this study were
from out of town. The use of telephone interviews enabled the investigator to
capture a variety of prospective from different regions of Ontario.
The results of this study demonstrated greater variation in decision-making
processes between CCACs than among case managers within CCACs. Hence
findings generated by this study would have been enriched with the adoption of a
larger sample of CCACs. Similarly the findings drawn from the responses to the
68
vignettes would be enhanced by the inclusion of a few more vignettes
representing clients with different set of characteristics (e.g. functional capacity).
The study relied on two vignettes to examine case managers’ decision making.
While vignette A and B were constructed to represent clients with a high and
moderate priority for rehab services based on their functional ability, these client
characteristics may not represent the entire homecare population. However,
patients in the vignettes share the characteristics of being homebound and
demonstrated safety concerns, two characteristics that tend to define clients
seen by OT and PT within the CCAC context. Furthermore the study relied on
two figures of same type (bar graph) to stimulate discussion amongst participant
regarding their value of aggregate data analysis in formulating decision for the
allocation of rehabilitation services. These discussions would have been
amplified by the addition of a few more figures of different types showing various
outcomes of clients.
The study relied on voluntary participation. Inherent to this method of recruitment
is the tendency of a biased sample of participants who are interested in therapy
services. For instance in response to the vignettes (A & B), all of the case
managers decided to provide OT or PT services or both (Appendix 1: Table 2 &
3, p. 80-81). However, 71.2% of the homecare clients with high needs for therapy
services never receive such services (Hirdes et al., 2004). This discrepancy
could be explained by the sampling bias or a social desirability bias amongst the
participants. The social desirability bias may have lead the participants modifying
69
their decision to provide therapy simply because they were being interviewed by
a student studying rehabilitation science. An additional vignette representing a
control client with no need for rehabilitation services would have been helpful to
confirm these biases amongst decision makers’ response to vignettes. To
minimize these biases, effort was given to record participants’ first reaction to the
case scenarios. For instance, the vignettes were emailed during the interviews to
avoid pre-constructed responses.
Direction for Future Research
The results of this study suggest the need for further research in many areas of
homecare. These areas include but not limited to the process of determining
therapy volume (Predetermined Vs Collaborative), the effect of various
inefficiencies in the system, validity of the rehabilitation algorithm embedded in
the contact assessment and the potential for more detailed presentation of
aggregate data to influence homecare case manager and supervisor decision-
making.
In this study, CCACs with higher referral rates to rehabilitation services within
their caseloads (referral rates being the sampling criteria for CCAC selection)
tended to use more collaborative decision-making approaches to therapy
allocation. Responses to the vignettes seemed to indicate that these CCACs also
seemed to allow for more therapy visits per patient. Future research is needed to
determine which approach leads to better client outcomes.
70
Various system factors were identified by the participants that affect the process
of homecare service allocation. Amongst these, the Ministry of Health and Long
Term Care (MOHLTC) funding scheme and the tendency not to share client
assessment information were acknowledged by multiple participants.
The current MOHLTC legislation requires that CCACs have to maintain a
balanced budget by the end of their fiscal year and that they receive funding only
for one year at a time. This funding method provides no incentive for the CCACs
to create efficiency in their service delivery. For instance if CCAC “A” (an
individual CCAC) implements a pilot program in search for a more efficient
method of service delivery, they may get penalized instead of being rewarded. In
this case, if CCAC “A” is unsuccessful in their attempt, they face the burden of
extra resources spent for the new program. On the other hand if they are
successful in their attempt, they are not allowed to keep the extra resources at
the end of their fiscal year. The extra resources are absorbed by the MOHLTC.
Future research should be directed toward examining the potential effects of
different funding schemes (multi vs. single year) within different parameters (2
years vs. 5 years) to come up with the most efficient model of CCAC funding.
The lack of communication of client information between case manager and
service providers has been identified to be a factor causing duplication of
assessments. Sharing information from the case manager assessment (RAI-HC)
71
with the service provider would increase efficiency and reduce duplication.
Participants recommended this action, but it is not clear whether they would be
willing to provide the necessary resources to support such information sharing.
Participants’ responses indicate that the clients described in both vignettes would
be referred to therapy services but the client in vignette B would have to wait
longer and receive a lower volume of service. This pattern of decision-making in
response to vignette A & B is in line with the rehab algorithm embedded in the
contact assessment. Further research is needed to validate the contact
assessment for various populations.
Participants of this study were very specific regarding their preferences for
outcome measures (i.e. ER visits, Falls etc.) and types of data analysis. Future
research should be directed to examine the effect of such analysis in changing
case managers practice.
72
Chapter 5: Conclusion
The process of decision making for the allocation of therapy services is
comprised of a series of stages called intake, assessment, referral to service
provider and reassessment. Amongst these the process of determining the
volume of therapy services in particular, varies widely across different region.
These variations are primarily due to the regional contextual (e.g. financial
constraints) factors experienced by individual CCACs. Future research should be
directed to explore the effect of these factors on client outcomes at the
population level and generate specific interventions to minimize these effects.
The participants’ pattern of decision making in response to client vignettes was
consistent with the contact assessment rehab urgency algorithm. The most
common rationale for providing rehab services is to ensure client safety.
Finally homecare decision makers in Ontario value aggregate data analysis
modeled on system-wide potential benefits (e.g. rate of LTC admission, hospital
admission and ER visits) and controlled for various client characteristics (e.g.
age, sex, cognition, diagnosis etc.). They have a particular interest in identifying
the profile of the clientele who can gain maximum benefit from services. Future
research should be directed to formulate such analysis of aggregate date and
examine their effect on homecare decision making.
73
Future research should determine the effect of various contextual factors on
client outcome, efficacy of different process of determining service volume in
improving client outcome and the effect of outcome research in changing
decision makers’ practice.
74
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Appendix 1: Tables and Figures
Table 1: Mean (Std Dev) PT or OT visits per client across 14 CCACs (Divided by Urban and Rural Areas)
CCAC Urban Rural
Mean (Std Dev) Mean (Std Dev) 1 0.243(0.429) 0.310(0.463) 2 0.257(0.437) 0.311(0.463) 3 0.325(0.468) 0.266(0.442) 4 0.449(0.497) 0.350(0.478) 5 0.344(0.475) 0.264(0.441) 6 0.462(0.499) 0.396(0.489) 7 0.391(0.488) 0.234(0.427) 8 0.365(0.481) 0.286(0.452) 9 0.210(0.407) 0.192(0.394)
10 0.325(0.469) 0.284(0.451) 11 0.286(0.452) 0.243(0.429) 12 0.316(0.465) 0.308(0.462) 13 0.266(0.442) N/A 14 0.483(0.500) 0.392(0.489)
Mean PT or OT visits in urban areas across all 14 CCACs (N=123590) = 0.339 (0.473) Mean PT or OT visits in rural areas across all 14 CCACs (N= 23056) = 0.296 (0.457) Method: Data sources were the 2006-2008 Ontario provincial home care data
holdings containing RAI-HC assessments linked to Home Care Database (HCD)
that records admission information, service utilization and discharge information
of the homecare clients. Bases on the RAI-HC assessments performed between
April 2006 and March 2008, a Logistic regression analysis has been performed
on PT or OT visits in both urban and rural setting. Urban and rural is identified by
the postal code of the client. The mean proportion of PT or OT visit in urban
settings is 0.339. The mean in rural setting is 0.269. Two CCACs bellow average
and two above average were sampled for this study (one rural and one urban in
each category).
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Table 2: Response to Vignette A
Participants PD
Decision
Other services Volume Reassessment Increasing Visit
Ivan SW Both Benchmark Based On Therapy Report
Karen SW Both SW Benchmark Based On Therapy Report
Based On Therapy Report
Naomi RN Both SW, PSW
OT: 2X, PT: 6X
Based On Therapy Report
Based On Therapy Report
Jodi RN OT SW 2X and Then Collaborative
Based On Therapy Report
Based On Therapy Report
Nathalie RN OT 2X and Then Collaborative 6 Months
Based On Therapy Report
Shirley PT PT PSW Collaborative Based On Therapy Report
Based On Therapy Report
Joana RN PT PSW Collaborative 3 - 6 Months Based On Therapy Report
Sharon RN PT PSW Collaborative 3 - 6 Months Based On Therapy Report
Kara OT OT PSW 2X and Then Collaborative
Based On Therapy Report
Cindy PT PT PSW Collaborative 3 - 6 Months
Need Manager’s Approval
Patricia SW Both PSW, MOW Collaborative 3 - 6 Months
Need Manager’s Approval
William SW OT PSW, MOW Care path
Based On Therapy Report
Based On Therapy Report
Maria SW OT PSW Care path Based On Therapy Report
Based On Therapy Report
Bob PT PT PSW Collaborative Based On Therapy Report
Based On Therapy Report
* CCAC Code Name (Table 1): RL =Green, UH= Pink, RH = Yellow and UL = Blue.
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Table 3: Response to Vignette B
Participants PD
Decision
Other services Volume Reassessment Increasing Visit
Ivan SW OT
Karen SW OT PSW increase 2x
Based On Therapy Report
Based On Therapy Report
Naomi RN OT SW 2x Based On Therapy Report
Based On Therapy Report
Jodi RN Both PSW Benchmark Based On Therapy Report
Based On Therapy Report
Nathalie RN PT Collaborative 4 Months
Based On Therapy Report
Shirley PT OT Collaborative Based On Therapy Report
Based On Therapy Report
Joana RN OT Transportation Collaborative
Telephone call in 4 weeks
Based On Therapy Report
Sharon RN PT Collaborative 6 Months Based On Therapy Report
Kara OT
Cindy PT PT Collaborative 3 - 6 Months
Need Manager’s Approval
Patricia SW OT Collaborative 6 Months
Need Manager’s Approval
William SW PT SW Care Path Based on PSW use
Based On Therapy Report
Maria SW PT
Community services Care Path
Based On Therapy Report
Based On Therapy Report
Bob PT OT 2X Based On Therapy Report
Based On Therapy Report
* CCAC Code Name (Table 1): RL =Green, UH= Pink, RH = Yellow and UL = Blue.
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Table 4: Reason for referral to rehab services
Participant Reason for referral to PT Reason for referral to OT Ivan Range of motion (ROM), Strength Home Safety
Karen Falls Equipment need, cognition, ADL, Transfer
Naomi Str Equipment need Jodi Mobility Home Safety
Nathalie Mobility, falls, Ambulation (amb), Strength, Transfer, endurance ADL, Cognition, Safety
Shirley Gait, transfer, balance Home Safety
Joana Fall, gait, strength, balance, exercise (exr), Equipment need, Home Safety
Sharon Gross Motor Fine Motor Kara Safety Safety
Cindy Mobility, falls, amb, Strength, Transfer, endurance Equipment need, Home Safety
Patricia Safety Equipment need, cognition, ADL, Transfer
William Pain, ROM, str Equipment need, Home Safety Maria ROM, LE Safety, UE
Bob Strength, Conditioning, endurance ,exr
Mental health dementia, cognition, safety
* CCAC Code Name (Table 1): RL =Green, UH= Pink, RH = Yellow and UL = Blue.
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Figure 1: Produced from 2006-2008 Ontario provincial home care data holdings
Discharged from home care with service plans complete within 6
months
0%
5%
10%
15%
20%
Received Home Care Rehab Did not receive Home Care Rehab
Figure 2: Produced from 2006-2008 Ontario provincial home care data holdings
Admitted to LTC home
0%
2%
4%
6%
8%
10%
12%
14%
16%
Received Home Care Rehab Did not receive Home Care Rehab
85
Figure 3: Variation of rehabilitation referral (PT and/or OT) across 14 CCACs for long-stay patient (Community –RAI Cases). (Poss, 2010)
Produced from Ontario provincial home care data holdings: Based On RAI-HCs done in the community from April 1, 2007 to March 30th, 2008 (N = 146,646) Figure 4: Rate of PT and/or OT by Rehabilitation Algorithm (Figure 5): (Categories are based on rehabilitation potential: Lower number = Higher Rehab Potential) (Poss, 2010)
14%
23%
33%
53% 57%
0%
10%
20%
30%
40%
50%
60%
5 4 3 2 1 % c
lient
s re
ceiv
ing
any
PT
or O
T
Rehabilitation algorithm value
Produced from Ontario provincial home care data holdings: Based On RAI-HCs done in the community from April 1, 2007 to March 30th, 2008 (N = 146,646)
86
Figure 5: Rehabilitation Algorithm embedded in the contact assessment (Lower number = Higher Rehab Potential)
87
Appendix 2: The Code Book Target Clientele of Homecare in Ontario Home care Clients Homebound vs Outpatients Rehab vs safety Homebound Medical Safety Source of referral Medical referral Self-referral Hospital referral Process of Decision Making CM assessment When RE-assess Time Done by the therapist Because of On going PSW Goal setting CM Client/family Therapist Guidelines for Home Care rehab PT OT available Reasons for referral to (Open) OT PT Safety Frequency of visits Predetermined Set by therapy committee (Benchmarks) Pathways Set by treating therapist Short term therapy Long term therapy Therapy Process Assessment Reporting
88
Increasing visits Response to Vignettes Reaction to Vignettes A and B: Chicken / anxious Process of decision-making Complexity Factors influencing vignette Potential for improvement Which services A or B Missing information Contextual Factors affecting decisions for homecare services Cost containment Reason Effect on visits Need multi-year budgets End of year spending Responses to cost containment Home care client Health care system Chonic disease client / legacy client Wait list number comes up Cost of Home Care One:one treatment - expensive Response to aggregate data analysis Data charts Inconclusive / lots of assumptions Depends on patient need Some don’t need rehab Very helpful- convincing Respect for research Need outcomes research Outcomes research to prioritize rehab services Where to make the biggest difference Ideal target population Economic analysis # of ER Visit # of hospital Admission RAI research Vacuum Helpful Priorities of Homecare Services
89
Caregiver burnout Relation to rehab services Priority issue Less falls NB Getting out of tub – not NB Rehab vs long term PSW Keep out of nursing home Nursing care Home support Therapists’ roles Turf vs role blurring
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Appendix 3: Data Collection Tools
Letter of Introduction Title of the Study: Rehabilitation in the Community: The Case Manager’s Perspective Dear Colleague, My Name is Abdur Rakib Mohammed. I am an MSc student in the Graduate Department of Rehabilitation Science at the University of Toronto. I am also a Physical Therapist by training. For my MSc research, I am exploring how Community Care Access Centre Case Managers decide when to refer home care physical therapy and occupational therapy services. The Purpose of the Study: To explore the decision-making processes used by Community Care Access Centre Case Managers to allocate physical therapy and occupational therapy services to home care clients. To examine the reasons for the CCAC Case Managers’ decisions to refer or not to refer physical therapy or occupational therapy services for home care clients. What you will do for the study: Your expertise as a CCAC case manager is a valuable resource to this research, and I invite you to participate in this research project. If you choose to be involved, you will be asked to participate in a confidential one-to-one interview (either in person or via telephone) with me at a private place, and a time that is convenient to you. The interview will last approximately 45 minutes to one hour, and will be tape-recorded. Potential Benefit: There are no direct benefits to you or the CCAC for your involvement in this study. Your contribution to this study would be used to report on how CCAC case managers are currently making decisions about referring occupational therapy and physical therapy to long term home care clients, and, why they are making these particular decisions. Potential Harms and Discomfort: You may experience some inconvenience due to time involved being interviewed (approximately 1 hour) and you may feel some anxiety knowing that they are being questioned on a topic that is currently of considerable interest. Finally, your name will not appear in any report or presentation. However, quotes from your interview may be included in reports or presentations. Although all efforts will be made to ensure confidentiality (that is, your name or other identifying information will not be included in any presentations or reports), there is a chance that someone may recognize your quotes.
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Confidentiality: The interviews are strictly confidential. The audio tapes will be stored until the end of the study and then erased. Your name and the names of others you mention will be replaced by codes. The codebook will be securely stored in a location separate from the transcriptions. All computer discs, audiotapes and written documents will be named with codes and securely stored. All identifying and potential identifying information will be removed from all publications and presentations arising form this research project. Voluntary Participation: Your participation in this study remains strictly voluntary and your informed consent is required to participate. You may drop out at anytime with no penalty. You can choose not to answer any questions. If you do withdraw from the study you will have the option of having any or all of the information you shared up to that point excluded from the study. Project completion: After the project is over you will receive a summary of the results if you wish. Questions: Thank you for considering this research. If you would like more information about this research project please contact me at [email protected]. If you have any questions about your rights as a participant, please contact the Office of Research Ethics at [email protected] or 416-946-3273, Yours sincerely, A. Rakib Mohammed M.Sc. Student Graduate Department of Rehabilitation Science 500 University Avenue, Suite 814 Toronto, Ontario Canada M5G 1V7 Phone: (416) 946 - 3941 Fax: (416) 946 - 8645 E-mail: [email protected] Katherine Berg Faculty Supervisor Department of Physical Therapy, Graduate Department of Rehabilitation Science 160-500 University Avenue Toronto, Ontario, M5G 1V7 Phone: (416) 978 - 0173 Fax: (416) 946 - 8561 Email: [email protected]
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Dr. Susan Rappolt Faculty Supervisor Department of Occupational Science and Occupational Therapy, and Graduate Department of Rehabilitation Science University of Toronto 160-500 University Avenue Toronto, Ontario, M5G 1V7 Phone: (416) 978-5936 Fax: (416) 946-8570 E-mail: [email protected]
Consent Form Title of the Study: Rehabilitation in the Community: The Case Manager’s Perspective Please complete this form bellow: A member of the research team has explained this study to me. I read the letter of introduction and understand what this study is about. I understand that I may drop out of the study at anytime without any consequences. Participant Name :…..……………………………………………………(Please Print) Participant Signature:………………………………………………………………. Witness Name:……………………………………………………………(Please Print) Witness Signature: ………………………………………………………………… Date:…………………………………………
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The Demographic Profile Entry level Professional Designation………………………………………………. Highest Degree achieved……………………………………………………………… Other degree or diploma…………………………………………………………….. Years of experience in a regulated health profession…………… Please specify your profession ……………………………. Name of the current employer (CCAC)……………………………………………… Years of service with the current employer…………………………………………. Years of experience as a Case manager /Administrator……………………………. Years of experience managing clinically complex clients…………………………
For the researcher only
Consent Received: Yes/No Interview Date: Interview Place:
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Interview guide
Introduction:
Thank you for participating in today's interview. I will start off by giving you a bit of background information. The objective of this study is to explore how decisions are made to allocate PT/OT for clients with long term condition. The principal investigator of the study is Katherine Berg, PT, PhD, Associate professor & Chair of the department of Physical Therapy, University of Toronto. In addition we have four co-investigators, three CCAC partners and myself, a Masters student at the Graduate Department of Rehabilitation Science at the University of Toronto.
I will ask you to discuss how you approach rehabilitation referral in your daily practice in general and how you normally recommend services for particular types of clients through vignettes representing typical homecare clients. The interview will last approximately one hour, will be tape-recorded and then transcribed word for word.
Open ended Questions Case Manager Administrator Ø In general, while managing your
clients, how do you decide when to refer to PT or OT?
Ø How do you develop the treatment
plan/goals? Ø How do you choose appropriate
services like PT or OT or Both? Ø How do you determine the
frequency and number of visits needed?
Ø Can you modify the frequency and
the visits if necessary? Ø Ideally client characteristics and
need and best practices should drive decisions of service planning. To what extent are other factors eg budgets influencing decisions in your CCAC?
Ø In general what type of clients do you think should receive PT or OT?
Ø Do you have any policy document
of organizational documents that provides guidelines on PT/OT referral?
Ø How do you think they determine
the type of service needed? Ø How do you think they decide about
the frequency and volume of the rehab services?
Ø Ideally client characteristics and
need and best practices should drive decisions of service planning. To what extent are other factors eg budgets influencing decisions in your CCAC?
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Probes for the Vignettes: Now I am going to move on to the second part of this interview. In this part I will ask you to make decisions regarding the allocation of rehabilitation for vignettes (A & B) representing typical homecare clients. You can use all of your typical assessment and decision support tools that is available to you in your daily practice. At the end of your assessment, I will ask you to answer the following questions for each of the vignettes (Same Questions will be asked for all the Vignettes). Vignette A: Mrs. Bond is an 85 year old female, lives in a two story house. She has a long list of medical conditions but they are all controlled by medications. Currently she is using a rollator for most of her mobility. Recently she started to have difficulty getting in/out of the bed, going down the stairs and walking long distances due to weakness and balance issues. She fell multiple times last month while going down the stairs but did not have any significant injury. She lives with her daughter, who recently started fulltime employment. Her personal health profile (PHP) is provided bellow. Her full RAI-HC 2.0 assessment is available on request.
Personal Health Profile (PHP) Personal Information
Age 85 Marital Status Widowed
Sex F Primary Language English
Health Profile
Reason for Referral [CC2] Rehab Mental Health
Cognitive Performance Scale [CPS] 0 Depression Rating Scale[DRS] 3 Possible Depression yes Experience Psychotic Episode [K3f or K3g] no
Communication
Making Self Understood [C2] yes Ability to Understand Others[C3] yes
Behavior Patterns
Wandering[E3a] no Verbally Abusive[E3b] no Physically Abusive[E3c] no
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Socially Inappropriate/Disruptive[E3d] no Resists Care[E3e] no
Social Functioning
At ease interacting with others[F1a] no Social Support
Care giver is unable to continue in caring activity [G2a] yes Care giver expresses feeling of distress, anger or depression [G2c] yes Primary care giver lives with client [G1ea] yes Relationship to client [G1fa] dtr Helps with ADLs [G1ia] yes
Elder Abuse
Potential Problem with elder abuse no Physical Functioning
Meal Preparation[h1aa] Need help Housework[h1ba] Need help Managing medication[h1da] Need help Transfer[H2b] Need help Locomotion in Home[H2c] Need help Eating[H2g] Supervision Potential for improvement in ADLs Yes Potential Problems related to falls Yes Falls frequency (Within 90 days) 3 Morbidly Obese[L1c] No
Medical Complexity
CHESS 2 Unstable cognition, ADL, mood or behavior patterns [K8b] yes
Pain
Pain Scale 2 Life Style
Smoked or Chewed Tobacco Daily[K7c] no Potential Problem related to alcohol dependence no
Skin Care
Potential Problem related to pressure ulcer no Skin problems no
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Formal Care of Dressing no Surgical Wound Care no other Wound/Ulcer Care no
Environmental Assessment
Hazardous Flooring in home yes Lack of Personal Safety yes Difficult access to home yes
Special Treatment
Oxygen[P2a] no Intravenous[P2h, P2i] no Tube feeding[L2d, L3] no Respirator[P2b] no Ostomy[P2k] no Dialysis[P2g] no Tracheotomy[P2m] no
Vignette B: Mrs. Jones is a 71 year old female, lives alone in a two story house. She has a long list of medical conditions but they are all controlled by medications. She also suffers from COPD and complains of SOB after prolong ambulation. Currently she is using a rollator for most of her mobility. She tripped on a piece of rug and fell about three months ago with no significant injuries. Since then she started having pain in her left Groin area after long distance walking. About a month ago she was hospitalized for urinary tract infection and developed significant weakness in her Bilateral Lower extremities. Currently she has significant difficulty doing the stairs. She also requires supervision for outdoor mobility. She receives Personal Support services twice a week for bathing. She heard about homecare PT/OT from her neighbor and referred herself to CCAC. Her personal health profile (PHP) is provided bellow. Her full RAI-HC 2.0 assessment is available on request.
Personal Health Profile (PHP) Personal Information
Age 71 Marital Status Widowed
Sex F Primary Language English
Health Profile
Reason for Referral [CC2] Rehab Mental Health
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Cognitive Performance Scale [CPS] 0 Depression Rating Scale[DRS] 5 Possible Depression yes Experience Psychotic Episode [K3f or K3g] no
Communication
Making Self Understood [C2] yes Ability to Understand Others[C3] yes
Behavior Patterns
Wandering[E3a] no Verbally Abusive[E3b] no Physically Abusive[E3c] no Socially Inappropriate/Disruptive[E3d] no Resists Care[E3e] no
Social Functioning
At ease interacting with others[F1a] no Social Support
Care giver is unable to continue in caring activity [G2a] n/a Care giver expresses feeling of distress, anger or depression [G2c] n/a Primary care giver lives with client [G1ea] no Relationship to client [G1fa] dtr Helps with ADLs [G1ia] no
Elder Abuse
Potential Problem with elder abuse no Physical Functioning
Meal Preparation[h1aa] ind Housework[h1ba] Need help Managing medication[h1da] ind Transfer[H2b] ind Locomotion in Home[H2c] ind Eating[H2g] Ind Potential for improvement in ADLs Yes Potential Problems related to falls Yes Falls frequency (Within 90 days) 1 Morbidly Obese[L1c] no
Medical Complexity
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CHESS 1 Unstable cognition, ADL, mood or behavior patterns [K8b] yes
Pain
Pain Scale 3 Life Style
Smoked or Chewed Tobacco Daily[K7c] no Potential Problem related to alcohol dependence no
Skin Care
Potential Problem related to pressure ulcer no Skin problems no Formal Care of Dressing no Surgical Wound Care no other Wound/Ulcer Care no
Environmental Assessment
Hazardous Flooring in home yes Lack of Personal Safety yes Difficult access to home yes
Special Treatment
Oxygen[P2a] no Intravenous[P2h, P2i] no Tube feeding[L2d, L3] no Respirator[P2b] no Ostomy[P2k] no Dialysis[P2g] no Tracheotomy[P2m] no
Semi-Structured Questions using vignette A and B Case manager Administrator Ø Would you refer this client to any
therapy services?
Ø What would be your main goals in service/care planning for this client?
Ø To which other providers would
Ø Do you expect this client to receive home care rehabilitation?
Ø To whom (OT or PT) and how much service should this client receive?
Ø What other services would be involved
e.g. PSW, nursing?
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Probes for the Data Charts: We are approaching to the final part of our interview. In this part I will show you two figures consisting analysis of RAI-HC data holding. These are examples of analysis that can be used to compare outcomes of clients who are and are not referred to rehabilitation.
Discharged from home care with service plans complete within 6
months
0%
5%
10%
15%
20%
Received Home Care Rehab Did not receive Home Care Rehab
Admitted to LTC home
0%
2%
4%
6%
8%
10%
12%
14%
16%
Received Home Care Rehab Did not receive Home Care Rehab
[The above figures are produced from 2006-2008 Ontario provincial home care data holdings. These figures are base on the entire homecare population.] I will ask you to comment on those figures using the following questions:
Semi-Structured questions using fact sheet Case manager Administrator Ø What do these graphs tell you?
Ø Are these figures helpful in showing
the benefit of rehab? Why or Why not?
Ø Is there any other outcome
measures or aggregate data analysis that you think are more helpful in your decision making regarding rehabilitation? If yes what are they?
Ø What do these graphs tell you?
Ø Are these figures helpful in showing the benefit of rehab? Why or Why not?
Ø Is there any other outcome
measures or aggregate data analysis that you think are more helpful in your decision making regarding rehabilitation? If yes what are they?
you refer the client? (e.g. PSW, Nurse, SW)
Ø How would you determine the frequency and the number of visits?
Ø Would you reassess this client?
Ø Do you think this client should be
reassessed to check if the goals were met?
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Do you have any other comments that you would like to make?
Please complete the demographic profile and email it back to me at your convenience.
Thank you for your participation. Your comments are most helpful. You have provided me with an informed perspective on your decision making for the allocation of rehabilitation services. Your contributions will help me discover the current framework of decision making and generate recommendation to improve it, if needed.
I may need to contact you again if I have problems with the quality of the audiotape from today’s interview. How can I contact you? When is the most convenient time for me to contact you?
Could you provide me with the names of case managers working with long term clients, Who may have a similar or different prospective then yours?
Description of Interview: Date, Time, duration, Place Informant’s appearance, affect Investigators affect, Does investigator previously know the informant? Environmental factors affecting interview (interruptions, noise) General impressions, emerging thoughts, ideas What went well/wrong, areas for improvement?
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