1. Work Survey Instrument Revision for Case Management Work Jane Christianson, RN; MSN L. Sue Davis, RN; PhD

2. Background Chronic diseases are #1 cause of death & disability in US & accounts for 75% of nation’s health care spending. Case management (CM) has the potential to decrease costs, provide safe, comprehensive, and coordinated care. CM has evolved rapidly during the last decade & instruments for studying the work of CM do not reflect the current roles or the complexity of the health care system.

3. Goals of Health Care Services Continuity of care across care givers and care sites. Culturally sensitive care and communication methods. Shared decision-making with patients and families in the development of a plan of care.

4. Case Management “A collaborative process of assessment, planning, facilitation and advocacy for options and services to meet an individual’s health needs through communication and available resources to promote quality cost-effective outcomes” (Case Management Society of America, 2008)

5. Issues blocking achievement of goals Multiple providers Communication issues Collaborative planning across settings Lack of patient/family participation Cultural differences Missing transitional care Insufficient information systems Case managers address these issues, but we lack an understanding of how these health care workers function in and across multiple settings.

6. Purpose of Study The purpose of this pilot study was to revise a work analysis instrument (WSI) that can be used to study case management work. Current instruments for assessing work functions and processes of health care workers do not consider the work of case managers. Case management work is “Invisible” and not readily understood by families or care providers. There is a need to understand case management work in order to ensure effectiveness and efficiency of the care management processes and to create a system that supports case management.

7. Aims of Study 1.Identify work characteristics of nurses/social workers who provide CM to chronically ill children and families. 2.Use the information on work characteristics to revise an existing work analysis instrument.

8. Aim # 1 Identify work characteristics of nurses/social workers who provide CM to chronically ill children and families. 5 focus groups of 2 to 5 CM participants. Sessions lasted approximately 1 to 1-1/2 hours. Participants were all experts in the role. Saturation of work functions were achieved with the 5 groups. Sessions were recorded and transcribed verbatim. Data were entered into NVivo 8 and analyzed for skills, knowledge, processes and concepts of CM.

9. Focus Group Results Theme I –Care Management is the glue that holds the care together. Theme II –Care Manager role reflects national standards. Theme III –Barriers reflect structural constraints.

10. Focus Group Findings: Theme 1 The Concepts –Collaboration –Advocacy –Communication –Resource mobilization –Attention to quality & cost

11. Focus Group Findings: Theme 2 Role Ambiguity in organizational position. Undervalued The CM work description closely matched the literature: –Standards of Practice –Roles & Functions

12. Focus Group Findings: Theme 2 A strong relationship with patients and their families and were highly trusted.

13. Focus Group Findings: Theme 2 Critical knowledge for role: –Pathophysiology of the disease process –Physician preferences & philosophy –Resources –Insurance & reimbursement –Organization –Strong nursing background –Child development & family theory –Culture –Basic research –Use of Information Technology critical (Described BSN a minimum criterion)

14. Focus Group Findings: Theme 2 Skills –Critical thinking –Problem solving –Multi-tasking –Communication –Interpersonal –Strong nursing background Characteristics –Persistence –Highly organized –curious –Detailed oriented

15. Focus Group Findings: Theme 3 Time and workload demands. –The CMs’ work was never completed in an eight hour shift and there was infrequent days off from work or the ability to leave the work at the office –The CMs found it impossible to attend hospital sponsored events, present at conferences, or develop evidence based practice. The CMs performed clerical and housekeeping duties –Scheduling appointments –Finding charts and reports –Copying material Invisible to management. –Unable to influence change because of the reporting structure. –Lack of governance structure to bring the CMs together to improve or evaluate the role.

16. Focus Group Analysis According to Tahan, Downey & Huber (2006) an 80% agreement between sample and national norms indicate sufficiency of practice. A 90% agreement was achieved, thus revisions based on focus group findings and national norms were reasonable to use in revision of the Work Analysis Instrument.

17. Revision of Work Analysis Instrument: Organizing Framework –Direct work – personal contact with patients and their families –Indirect work client related – work activities that are performed away from the patient and their families in the patient’s behalf –Indirect work non-client related – work activities that facilitates the success of direct work and indirect work client related; however, not directly contributed to the health & well being of specific patients –Management work – work activities that support ongoing operational effectiveness –Professional & Career - formal and informal enrichment activities

18. Revision of Work Analysis Instrument: Organizing Framework –From the qualitative analysis, subcategories of work were identified and grouped using the organizing framework. –Definitions were created for each of these subcategories. –Three experts separately sorted work tasks into the subcategories of work. –Discrepancies were discussed and consensus was achieved. –Groupings and tasks were reviewed by two expert case managers and who made suggestions for change.

19. Testing revised instrument The instrument is currently under pilot testing with a group of nurses with CM responsibilities. The revised instrument will next be used in a larger study to further understand the work of CM. Results will be used to design a CM model as a framework for organizing the work of CM.

20. Relevant to Nora Priorities Relevant to NORA priority; improved workplace practice Improved workplace practice will result in improved medical outcomes, timely management of chronic diseases, increased patient safety, and reduction in healthcare costs

21. Acknowledgement “This research study was (partially) supported by the National Institute for Occupational Safety and Health Pilot Research Project Training Program of the University of Cincinnati Educational and Research Center Grant #T42/OH008432-04”.