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Assessing Need for Intensive Case Management in Long-Term Care

^a School of Social Work, Georgia State University, Atlanta
^b Community Care Services Program, Visiting Nurse Health Systems, Atlanta, GA
^c Senior Unit, Ridgeview Institute, Smyrna, GA
^d School of Social Work, Georgia State University, Atlanta

Correspondence: Sadhna Diwan, PhD, School of Social Work, Georgia State University, Atlanta, GA 30303. E-mail: sdiwan{at}gsu.edu.

Decision Editor: Eleanor S. McConnell, RN, PhD

	Abstract

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This article presents a brief screening tool to help case managers identify clients in a home- and community-based services (HCBS) program who need more intensive social work case management (CM). Using existing data from a case management time study (N = 242) and a content analysis of 70 cases in a Medicaid waiver–funded HCBS program, this study highlights a number of issues, such as dementia-related behavior problems, noncompliance with treatment, poor informal caregiver health and mental health, and a conflicted or problematic relationship between client and caregiver, which are useful in predicting need for intensive case management. Kappas for interrater reliability and t tests for discriminant validity show these items to be reliable and valid. This tool will allow for better allocation of CM resources in terms of case manager time and type of expertise needed to address these issues.

Key Words: Risk identification • Older adults • Intensive case management • Social work practice

Long-term care case management is generally viewed as an undifferentiated, administrative activity in most home- and community-based services (HCBS) programs ( Newcomer, Arnsberger, and Zhang 1997). Case management activity typically consists of an assessment of individual needs, the brokering of in-home services, and ongoing monitoring of the care plan. The implicit assumption is that a long-term care client can be maintained in the community simply by providing the typical range of supportive services such as homemaker, home health aide, nursing care, meals, and respite care. A large proportion of individuals in HCBS programs are cared for by family members and need only minimal to moderate levels of case manager oversight to arrange for and monitor supportive services. However, a significant number of people in these programs have individual or family problems that require a greater level of case management in terms of monitoring as well as intervention skill to maintain these clients safely in the community. Behaviors such as noncompliance with treatment, personality issues (e.g., being overly demanding of service providers), and conflicts between the client and caregiver can interfere with the maintenance of a successful care plan. In such instances, case managers report needing extra time and skills to deal with these problems effectively. The presence of "clinical" issues in case management practice have been noted by others such as Burack-Weiss 1988 and Morrow-Howell 1992, but as Austin 1996 observes, the theoretical and practice literature on long-term care case management devotes little attention to issues related to mental health counseling and psychosocial issues. Furthermore, the tendency of policy makers to view case management as an administrative activity with little intrinsic value added to the long-term care system has resulted in a trend toward larger caseload sizes and case management programs that are able to offer little more than service brokerage functions.

What are the consequences of unmet needs for appropriate case management? If a client's situation calls for a level of case management that a program is unable to provide, it is likely that this mismatch will defeat the goals of the HCBS program, which is to keep the client in the community and avoid or delay institutionalization. Not addressing these problems adequately may result in a shorter community stay for the client especially if the client's safety is at issue. Quality of care in the community setting is also compromised if case management services are not matched to client needs.

With the expansion of Medicaid-funded HCBS programs, all of which offer case management as a core service, it is becoming necessary to develop a better understanding of who needs how much and what type of case management. In an effort to address this issue, the case management program discussed in this article has begun to examine and categorize the type of client situations that call for more intensive case management to effectively maintain clients in the community. Based on a review of client charts, a brief screening tool was developed that has been used by case managers to determine which of their clients were likely to need intensive case management services. The purpose of the tool was to provide case managers with an empirically based mechanism that would identify clients with greater needs and allow a justification of differential allocation of case management resources in the program.

	Identifying Need for Intensive Case Management

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Practitioners and researchers have been grappling with the problem of how to identify those who may benefit from more intensive case management. The primary belief underlying this issue is that people have different needs and problems, and that the level of case management ought to correspond better with the varied levels of client needs. Level or intensity of case management refers to both the amount of time spent on a case as well as the focus of the case management activity, which can include brokering for services, problem solving, counseling the client and the family, advocacy, and resource development.

The ecological approach to understanding human behavior provides the basis for identification and classification of clients with differing needs for case management services. This approach examines the degree of fit between person and environment and directs practitioners to develop interventions that affect the transactions between the person and environment ( Lewis and Greene 1994). Applied to case management practice, this approach would encourage interventions that meet specific individual needs rather than using a cookie-cutter approach (see Kane 1995) to case management. By addressing the unique needs of individual clients, case managers are able to meet client needs more effectively while maintaining the client's autonomy, self-determination, and dignity.

Several different approaches have been used to determine allocation of case management resources. One approach has been to allocate case management to clients based upon preselected criteria that are used to determine who will get what level of case management ( Applebaum and Mayberry 1996). Other studies in the literature have targeted specific subgroups of clients (e.g., people with dementia) for intensive case management ( Newcomer et al. 1997; Challis, von Abendorff, Brown, and Chesterman 1997). Another approach has been to empirically examine the characteristics of clients and caregivers to determine aspects of their situations that lead to increased use of case management resources ( Diwan 1999).

One study found dementia-related behavior problems to be predictive of greater use of case manager time ( Diwan and Phillips 2001). Other problematic client and caregiver characteristics, however, have not been examined separately to assess their individual impact on case management time. The efficacy of intensive case management with clients with dementia has already been demonstrated in earlier studies (see Challis et al. 1997; Eggert, Friedman, and Zimmer 1990; Newcomer et al. 1997). Yet, although persons with Alzheimer's or other dementias constitute a significant portion of the participants in HCBS programs, there are many other clients who need more intensive case management but who have not been targeted to receive such services in most HCBS programs.

Time studies of case management activity ( Diwan 1999; Kemper 1990) have shown that most clients need a larger amount of case management activity at the time of assessment or reassessment, but this activity gradually decreases over time as the care plan is implemented and the client's needs have been addressed. However, case managers report the existence of a group of clients who repeatedly go through cycles of high case management activity. The problems encountered in these cases tend to disrupt the care plans that are developed for the clients and necessitate intensive case management. The focus of case management in such cases is either to stabilize the situation or to discharge the client from the program as the client can no longer be maintained in the community. Developing a better profile of these types of client situations will assist in developing more appropriate strategies to manage these cases more effectively. This study extends earlier work on the allocation of case management resources through a qualitative analysis of data that provides case managers with a brief assessment tool that includes descriptive as well as empirical information on the various client and caregiver characteristics that call for a more intensive model of case management.

	Methods

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The case management program used for this study is funded through a Medicaid Waiver for home- and community-based services. Clients are assigned to a case manager by service area rather than on the basis of any particular client or case manager characteristic. The professional training of case managers is varied and includes social work, psychology/counseling, sociology, gerontology, and public services. This case management agency not only emphasizes higher education and relevant experience among its case managers, it also has a strong quality assurance program that includes individual and group supervision, clinical supervision, and ongoing staff development workshops. All these activities help ensure that clients receive a fairly uniform and high level of case management service.

Both qualitative and quantitative methods of analysis were used to develop the brief tool to identify clients needing more intensive case management. Each of these methods is described below. Seventy cases that had been identified by 11 case managers as needing intensive case management were first analyzed for content. The case managers were asked to select cases based on any of the following criteria: (a) they perceived the case to require a great deal of their attention and time; (b) they experienced more than average difficulty in successfully implementing a care plan; or (c) the cases experienced repeated "crisis" episodes that needed intensive intervention. Although the criteria for selecting cases to be included in the study were subjective, the cases selected by the 11 case managers were remarkably similar in the overall nature of the issues confronting the case manager.

Cross-case analysis was the method used to identify distinct clusters or families of cases. The common strategy for data analysis using this method is to find themes that cut across cases (see Huberman and Miles 1994). Based on an initial review of the cases, common themes were extracted and developed into several broad categories or predictor variables. The data were reexamined to understand the particular configurations within each case, that is, the issues or problems that appeared to accompany the particular predictor variables. For approximately half of the sample cases (n = 33), two raters were asked to read each case and note the presence or absence of the predictor variables. This step was necessary to ensure reliability or consistency in coding the variables using the information in the charts. The Kappa statistic was used to assess the interrater reliability for coding the predictor variables.

Using an existing data set on the use of case management time in this HCBS program, the discriminant validity of these predictor variables was assessed through the use of t tests to determine whether these variables could differentiate between high and low users of case management time. The sample in this data set consisted of 242 randomly selected clients in the same HCBS program who were tracked over a 4-month period for the amount of case management time spent. This data set also contained information on demographic characteristics, health and functional status, and other problems/issues related to clients, informal caregivers, and formal service providers. This sample and the setting have been described in detail elsewhere ( Diwan 1999).

To extract themes from qualitative data, Dey 1993 notes that some categories can be developed a priori guided by theory or previous research and experience. Other categories are developed, or differentiation within categories occurs, through closer inspection of the data. Based on previous work on predictors of intensive case management and additional insight obtained through conversations with case management staff, we created an initial matrix that contained three broad categories: client behavior and personality characteristics; informal caregiver behavior and personality characteristics; and client's medical condition or frailty. On this matrix each case also had a comment section for brief descriptions of issues pertaining to each category. A review of these comments after the initial coding enabled us to further refine the client and caregiver characteristics, leading to the development of additional subcategories. Thus, within client characteristics, the major variables or themes were the client's cognitive status (dementia and its accompanying problem behaviors), the client's mental or emotional state (diagnosed mental illness and its accompanying problem behaviors), and the client's personality characteristics that created difficulties for case managers and service providers. Under informal caregiver characteristics, the major categories were caregiver burnout or stress, the caregiver's personality characteristics, and a problematic relationship between caregiver and client. A second matrix to note the presence of these new variables or subcategories was created and the data were reviewed again to complete this matrix. The specific descriptions of each variable and item are outlined in Table 1 .

	Results

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Common Themes
Clients With Dementia and Behavior Problems.
Clients with dementia may exhibit behaviors that are difficult to manage. These behaviors include having poor judgment, being argumentative, being forgetful, getting easily confused, and wandering. Problems associated with these behaviors include noncompliance with treatment, resistance to care, mistrust of aides, and caregiver burnout. Twenty-seven percent (n = 19) of the cases belonged to this category.

Clients With Mental Health Problems.
Clients with mental health and substance abuse problems can be difficult to manage as they may engage in dangerous behaviors. For example, clients may exhibit paranoid or suicidal ideation, be noncompliant with treatment, and create difficulties for the aides who provide services. Chronic pain or physical problems may also create depression and/or substance abuse that need to be addressed. Twenty-seven percent (n = 19) of the cases belonged to this category.

Clients with Difficult, Demanding Personality Characteristics.
Some clients enter the long-term care system with lifelong personality characteristics or behaviors that are associated with dependent, borderline, or narcissistic personality disorders. Such behavior traits create difficulties for case managers and service providers. For example, clients who are very anxious may call the case manager every day or even several times a day; clients may expect more service than can be offered and be overly demanding. One client complained that the aides were "too dressed up to do their jobs." Another client only wanted an "American" male aide. Some clients are rude to the aides who then refuse to serve the clients. Other difficult characteristics include noncompliance with diet, medication, and other prescribed treatments not related to a diagnosis of dementia or mental illness. Twenty-four percent (n = 17) of the cases belonged to this category.

Medically Frail Clients.
Clients who had multiple diagnoses, were experiencing pain, had respiratory illnesses, and were prone to falling due to gait problems and dizziness appeared to require more case manager attention. These clients were likely to have more hospitalizations as there were either no informal caregivers or the caregivers did not know how to manage the client's condition and therefore sought hospitalization. Sixty-eight percent (n = 48) of the cases belonged to this category.

Informal Caregiver Stress/Burnout.
Informal caregivers are prone to experiencing burnout when they have other responsibilities. This is especially true when the client is medically frail and requires 24-hour care. Potential problems include the caregiver's own health problems, feelings of guilt and inadequacy, and depression. Twenty-eight percent (n = 20) of the cases belonged to this category.

Problematic Caregiver Personality or Behaviors.
Caregivers may be difficult to work with because they give false information about the client's finances or they misuse services by asking the aides to do extra work for the caregiver. Other caregivers can be very demanding, picky, and rigid about service provider schedules, which creates obvious strain on the service providers. In these situations case managers have to spend much time trying to work with caregivers and service providers to ensure the implementation of a care plan that meets the needs of the client. Twenty-three percent (n = 16) of the cases belonged to this category.

Problematic Relationship Between Client and Informal Caregiver.
When the caregiver herself has emotional problems, this may result in a hostile or strained relationship between client and caregiver. The caregiver can also be abusive or neglectful toward the client, especially when the caregiver depends on the client's income. Lack of family support or involvement with a client's care, or erratic, unreliable support also contributes to a difficult case management situation. Twenty-three percent (n = 16) of the cases belonged to this category.

Summary.
Thus, 34% of the cases (n = 28) had problematic caregiver characteristics, 27% (n = 19) had problematic client characteristics, and 27% (n = 19) had a combination of problematic client and caregiver characteristics. The remaining eight cases (11%) were related to medical frailty because of conditions that were difficult to manage or to situational problems, such as difficulty with locating appropriate service providers either due to staffing issues at the provider agency or the lack of services in more rural parts of the metropolitan area.

Interrater Reliability and Discriminant Validity
Based on the seven themes and their accompanying problems, nine items were developed into a screening tool to identify need for more intensive case management (see Table 1 ). Based on previous research ( Diwan 1999), we decided to tease out the impact of simply having a diagnosis of dementia and mental illness separately from having accompanying problem behaviors and emotions that might require more intensive case management.

Selecting approximately half of the sample (n = 33), two raters noted the presence or absence of each item or variable in each case. Both raters were graduate students (one in social work, the other in counseling) with some clinical experience in gerontology. The coders noted the presence of a variable over a duration of a 12–18 month period. The problems could have been noted at the initial assessment or during the course of managing the case.

Kappa scores were calculated for each variable to assess the degree of agreement between the raters on the nine items in the screening tool. In general, as Table 1 indicates, there was high agreement on the coding of all variables (kappa .80 or above) except for the item that assessed the medical frailty of the client (kappa = .34).

To assess the discriminant validity of the items, t tests were run for all items using an existing data set on the use of case management time. The following items were found to be significant: client's behavior problems; client's noncompliance with recommended treatment; client's psychological or emotional problems; caregiver's feeling of being stressed or burnt out; caregiver's difficult behaviors or personality traits; and a problematic relationship between client and caregiver. The two case vignettes in the Appendix provide a more complete picture of these issues as they arise in case management practice.

	Discussion

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This study extends previous work on high-risk or high-demand clients in long-term care by providing case managers with a brief, easy-to-use, empirically validated screening tool that helps case managers identify individuals in HCBS programs who need more intensive case management. As indicated in the Results, dementia and mental illness alone are not significant predictors of the need for intensive case management. Rather it is the presence of untreated psychological or behavioral issues that necessitates greater case management activity. Therefore, clients with dementia or mental illness would not automatically trigger a need for more intensive case management, but such clients would require additional oversight to monitor changing conditions. Furthermore, both informal and formal caregivers need to be trained to identify these problems early so that adequate care planning can be accomplished.

Most HCBS programs use assessment tools that include standardized measures for functional ability, mood, social support, cognitive functioning, health, and disease. The assessment questions typically provide a profile of the client's unmet needs for HCBS services, but are seldom used to determine need for more intensive social work case management. The items presented in our brief assessment tool are based on existing questions used for assessment but have been modified to provide more useful information. This tool can be used at the time of initial assessment or reassessment to identify demanding cases. Most case management program guidelines require case managers to visit clients periodically (every 4–6 months) to review and adjust the care plan as needed. Using the tool at these care plan reviews would also help identify problems that require more intensive case management. However, problematic situations can arise at any point during the course of a client's stay in the program and typically these cases come to the case manager's attention because of the "squeaky" nature of their problems. Case managers need to be sensitized to these issues and trained to identify and respond to them as the need arises.

There is some evidence in the literature that case managers do attend to high-risk clients by offering them service options that can better match their needs. For example, Hennessy 1989 describes case managers in a capitated long-term care program who could shift high-demand clients among various service options such as adult day care and assisted living to better meet the client's need for supervision. These options, however, relate to the use of different services rather than a different approach to case management, which is needed to address many of the other issues described earlier. Similarly, programs may also shift clients among colleagues when the need arises. However, few programs offer any specialized case management to address particular client needs.

The advantage of an empirically derived screening tool is that it offers the basis for matching case management services to client needs and points to specific areas of intervention. The risk tool can be used to screen clients for whom clinical protocols need to be implemented. Whereas HCBS programs are geared to meet the physical care needs of older individuals (through the provision of in-home services), most find it difficult to adequately address psychological and behavioral issues that often jeopardize the client's ability to remain in the community. Classification of clients who require intensive case management services also sets up the foundation for research on interventions that address the clients' situations and meet the goals of the HCBS program. Such interventions include individual and family counseling, caregiver education and support for the management of dementia and other mental disorders, and the implementation of care management protocols that have been tested for their efficacy in producing the desired client outcomes. Case managers will need to be trained to use a variety of care management protocols that are available.

One limitation of this tool is that the responses to the items depend somewhat on the case manager's subjective assessment of the client–caregiver relationship. Thus, inexperienced case managers may likely rate some issues as needing more time and skill or may have greater difficulty in addressing certain problems because of their personal experiences or lack of knowledge. Clemens and Hayes 1997 found a great deal of variability in case managers' subjective assessment of client risk. They note that the implicit use of "labels" for client behaviors and personality characteristics had an impact on the care recommendations that were made, leading to the possibility that similar clients would receive very different recommendations depending on their case managers. This issue needs to be addressed through training and supervision. That is, although the risk tool contains both objective and subjective indicators of problematic situations, identifying problematic cases then allows for a more objective response through the triggering of specific protocols designed to address specific needs. One practice that has already been instituted in this case management agency is the use of case conferences to discuss difficult clients and "clinical" supervision for case managers who are struggling with these and other issues. These practice methods together with a standardized and empirically validated risk assessment tool can be instrumental in reducing the variability in care plan recommendations that are attributed to case manager knowledge and experience.

Given that many cases may go through crisis episodes that can be stabilized for a period of time, a team approach to case management may offer one way to successfully manage large and diverse caseloads. For example, in some agencies, a nurse, a social worker, and a case aide are part of a team that manages a client ( Eggert et al. 1990). The aide handles routine case management tasks, thereby freeing the nurse and social worker to focus on more acute problems that require greater intervention skills.

The lack of significance of the variable assessing medical frailty points to areas for further study, that is, how to identify clients who need a greater level of medical or nursing case management. This variable had low interrater reliability and discriminant validity. This may partly be explained by the fact that the coders' professional affiliations were social work and counseling rather than nursing, which could have influenced their coding. However, a more significant problem in identifying such cases is the lack of adequate indicators and documentation of these indicators in the client's chart. Given that social work case managers have the most frequent ongoing contact with the clients, this case management program is working to develop a set of indicators whereby the case manager can identify and call for greater nursing oversight for medically frail clients.

Thus, identification of clients in need of more intensive case management is consistent with the ecological approach of looking at the person-in-environment. Tailoring case management services to meet client needs should enable clients to stay in the community longer, experience better quality of life, and have greater satisfaction with the home care program.

	Acknowledgments

 
This study was made possible in part by an NIA training grant (T32-AG0017). The School of Social Work and the Gerontology Center at Georgia State University also provided research support. The authors thank the Division of Aging, Georgia Department of Human Resources and Visiting Nurse Health Systems for their support, and thank the two anonymous reviewers for their comments on earlier drafts of this article. Any views expressed in this article are those of the authors.

Received for publication September 5, 2000. Accepted for publication April 27, 2001.

	Appendix

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Case Vignettes
Case 1
A 90-year-old female client, who did not have a formal diagnosis of dementia, began to manifest behaviors such as forgetfulness and confusion. At the beginning of this case, the client appeared friendly and talkative. Her home was neatly maintained and she kept herself active with exercise. She lived alone but had very supportive neighbors. Due to a decrease in mobility related to her arthritis, she needed some assistance with ADLs and IADLs. Overall, her physical health was good as she had one diagnosis of arthritis and one prescribed medication to relieve its symptoms. As the case continued, there was a question of a small stroke or TIA. She began to exhibit agitated behavior including verbal abuse, cursing, and racial slurs, all of which were directed toward the case manager and aides. Increased confusion and forgetfulness became evident when the client would accuse the staff of stealing items, including stockings and nightgowns from the home only to find them later. The client was easily angered and difficult to please. Eventually, aides began to refuse to return to the home. This left the case manager with the task of re-brokering for services to keep the client within her home. Several calls were also made to the client's physician for further input on the case. The client and case manager began to look into alternative living arrangements as it became clear that the client was at considerable risk living alone.

Case 2
A 78-year-old widowed woman, diagnosed as having dementia, was accepted into the program. She was noted to be alert, friendly, cooperative, and she needed assistance with ADLs and 24-hour supervision. The client lived with her daughter (the primary caregiver), a recently divorced mother with one son. The caregiver struggled with physical problems including wrist, back and neck pain for which she had some surgery. From the beginning, the caregiver's behavior was noted as being demanding, argumentative and difficult to appease. The case manager noted the caregiver's tendency to be irrational, to make quick accusations of discrimination, and threats of legal action. There were multiple calls to the case manager on a daily basis both from the caregiver and the provider agencies that often resulted in services being rebrokered. Over a 5-month period, services were re-brokered seven times. At one point, the caregiver filed a complaint against the senior center's transportation rather than accommodating the center's request for a compromise related to the services provided to the client. Another incident resulted in an aide being arrested after the caregiver filed charges of breaking and entering and burglary. The charges were eventually dismissed but it required a change of agencies. Eventually, other agencies refused services to the client for fear of legal action by the caregiver. Due to the intensity of the case, the case management supervisor was asked to intervene. The program considered not continuing to broker in-home services due to the frequent caregiver accusations. The difficult behaviors of the caregiver decreased somewhat over time but she continued to demand that aides do work that was beyond their mandate. Throughout the case narrative, very few of the case manager's extensive efforts were directly related to the client's needs, but rather to managing the informal caregiver whose support was necessary to keep the client in the community.

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