How would case managers' practice change in a consumer-directed care environment in Australia?

Developing an Operationalized Framework for Comparing Consumer-Directed Care for Older Adults: Evidence from Expert Survey and Cross-National Comparison

Consumer-directed care (CDC) programs for older people aim to optimize health outcomes by offering clients control and flexibility regarding service arrangements. However, policy design features may differ due to heterogenous sociostructural systems. By operationalizing a framework with three dimensions of CDC, i.e. control and direct services, variety of service options, and information and support, we analyzed how countries vary in their policy designs to achieve consumer direction. Using an expert survey (n = 20) and cross-national document analysis, we analyzed 12 CDC programs from seven selected countries: the United States, the United Kingdom, Germany, the Netherlands, China, Australia, and Spain. Among the three dimensions, CDC programs placed more emphasis on and displayed more homogenous performance of policy designs that achieve consumer direction in the dimension of control and direct services, while less emphasis was placed on and more heterogenous performance displayed in the dimensions of variety of service options and information and support. We offer a systematically operationalized framework to investigate CDC policy designs. Findings advance our understanding of CDC policy features from a cross-national perspective. Policymakers could incorporate these findings to empower older people in their respective societies.

Consumer direction in the field of digital technologies and people with dementia: a literature review

PURPOSE

Digital technologies have a great potential to improve the quality of life of people with dementia. However, this group is usually not involved in their development and dissemination. A consumer-directed role in the delivery of digital technologies could allow this group to regain autonomy and certain independence. This article aims to conceptualise the components of the Consumer Direction theory in the context of digital technologies and people with dementia.

METHOD

A literature review was conducted. We searched for studies within the aforementioned context in five relevant databases, covering the years 2012-2020. Identified studies were screened and assessed for inclusion. The data were categorised using two-stage qualitative content analysis.

RESULTS

Forty articles were included. The results provide definitions of the four components of the Consumer Direction theory in the context of this study. Namely, what it means for people with dementia to be (1) in control of technology use, (2) offered a variety of technological options, (3) informed and supported regarding the use and training of digital technologies, and (4) actively participating in systems design. These can lead to the empowerment of people with dementia.

CONCLUSION

The four theoretical components of the Consumer Direction theory are conceptualised differently in the context of this study. By providing new definitions, this paper contributes to research and practice. We expect the definitions to be deployed by researchers, practitioners, and policymakers for the creation of a more consumer-directed delivery of digital technologies to people with dementia.Implications for rehabilitationDigital technologies have a great potential to improve the quality of life of people with dementia.A consumer-directed role in the delivery of digital technologies could empower people with dementia and give them the opportunity to take control over the offered services as well as maintain a degree of independence.The Consumer Direction theory and its components should be conceptualised differently in the context of digital technologies and people with dementia than in previous contexts that used the theory.The new definitions can be utilised by researchers, practitioners and policymakers for the creation of a more consumer-directed delivery of digital technologies to people with dementia.

Community mental health funding, stakeholder engagement and outcomes: a realist synthesis

Mental health services continues to be a high priority for healthcare and social service systems. Funding structures within community mental health settings have shown to impact service providers' behaviour and practices. Additionally, stakeholder engagement is suggested as an important mechanism to achieving the intended goals. However, the literature on community mental health funding reform and associated outcomes is inconsistent and there are no consistent best practices for stakeholder engagement in such efforts.

OBJECTIVES

This study sought to understand how stakeholder engagement impacts outcomes when there is a change in public funding within community mental health settings.

DESIGN

A realist synthesis approach was used to address the research question to fully understand the role of stakeholder engagement as a mechanism in achieving outcomes (system and service user) in the context of community mental health service reform. An iterative process was used to identify programme theories and context-mechanism-outcome configurations within the literature.

RESULTS

Findings highlight that in the absence of stakeholder engagement, funding changes may lead to negative outcomes. When stakeholders were engaged in some form, funding changes were more often associated with positive outcomes. Stakeholder engagement is multifaceted and requires considerable time and investment to support achieving intended outcomes when funding changes are implemented.

CONCLUSIONS

To support successful transformation of community mental health programmes, it is important that stakeholders are meaningfully engaged during funding allocation changes. Stakeholder engagement may entail connecting around a shared purpose, individual participation and meaningful interactions and dialogue.

Perspectives and practices associated with consumer-directed care in Australia: Synergies and tensions in supporting planning and delivery of home care for older people with dementia

This study used a qualitative, cross-sectional design to address a gap in understanding the perspectives and practices of care planners and case managers in supporting consumer- directed care (CDC) for community dwelling people living with dementia. Semi-structured telephone interviews were conducted with a convenience sample of n = 16 planners and managers from seven providers of the Australian home care packages (HCP) program in NSW (Australia). All interviewees described the aspirations of supporting choice within CDC as synergistic with their values and with person-centred care. Some described new flexibilities within the more open-ended planning conversations enabled by CDC. However, most acknowledged their capacity to enable choice for clients with dementia was limited by the capped care budgets, as well as the skills and time needed to support choice and decision- making. Organisational practice changes associated with the shift to a market-based system were also perceived as limiting the capacity to support choices. Reducing centralised systems, increasing individual budgets and improving staff capacity to support decision-making by people with dementia may help to improve this situation. However, results suggest a deeper need to re-evaluate whether the CDC model is the most appropriate for supporting the rising numbers of people with dementia to age well in place.

What Injured Workers With Complex Claims Look For in Online Communities: Netnographic Analysis

Background

Improved understanding of social constructs around injury may help insurance case managers to understand how best to support people after injury.

Objective

This study sought to explore what people who sustain work-related injuries may seek from online communities. The study highlights potential opportunities for improved engagement with insurance case management practice.

Methods

An observational netnographic analysis was undertaken on anonymous, publicly available messages posted on Australian message boards. All research data were drawn from anonymous, online communities. A person (author SM) with experience of making a claim through an Australian workers’ compensation system and online engagement was involved in study conception, design, and analysis. Data were analyzed using NVivo12 in an iterative, multistage process including coding, journaling, and member checking. A total of 141 people were engaged in discussion across 47 threads housed on 4 Australian forums.

Results

In this qualitative study, themes emerged from the data, describing how injured workers use online communities to help make decisions, get support, and solve problems. The key motivators for action and engagement were seeking information, connection, or justice. Establishment of relationships was a key mediator of each of these parameters.

Conclusions

Some work-related injuries may involve medical and medicolegal complexity as well as changed lifestyle and routine during convalescence and recovery. The mechanism used by some injured workers to seek information and problem solve suggests a capacity for self-management and self-care after work-related injury. Netnography provides information on a community that may not regularly engage with research because of the complexity of their situation and their vulnerability.

Consumer directed care aged care reforms in Australia since 2009: A retrospective policy analysis

In 2009, the Australian federal government used the projected rise in aged care expenditure and changing societal attitudes to justify the decision to overhaul the funding for aged healthcare services. A major feature of the reforms was the introduction of a consumer directed care (CDC) model. This followed the UK, Sweden, Canada and the USA who had already implemented CDC to some degree. The CDC model transferred aged care decisions from providers to consumers. This promised to create a competitive market system, resulting in decreased costs, increased quality and increased consumer satisfaction of aged healthcare services. Advocacy services were also reformed to address market failures. These changes were achieved by engaging key actors throughout the policy cycle, giving perceived legitimacy and transparency; and commissioning reviews with restricted scope and at calculated times, limiting their ability to produce negative criticism. In July 2018, the federal government gained full funding and responsibility for aged care with the support of key stakeholders and multiple reviews, yet with little objective data on the benefit of the reforms. This analysis highlights the power of the policymaking process in creating policies.

Consumer expectations of self-managing aged home care packages in Australia

This study investigated the expectations of older people who chose to participate in a self-management trial of home aged care packages conducted by COTA Australia. Empowerment theory is used to interpret the findings. All Australian home aged care support packages are delivered using a consumer directed care (CDC) model, and most are managed by an aged care provider. The COTA Australia trial gave older people the opportunity to self-manage their package and have more control over spending and less constraints on its use. This study examined three questions: (a) what motivated the older person, or an informal carer acting on their behalf, to participate in the self-managing trial; (b) what outcomes they expected (c) and what was their attitude towards risk. The trial was conducted over 9 months in 2018-2019. Seven registered home aged care providers from six Australian states and territories recruited 103 consumers to the trial, with having an informal carer act on their behalf. Online questionnaires with consumers (n = 103) and informal carers (n = 66), and 18 semi-structured interviews showed that older consumers and their informal carers had high expectations that self-management would result in: increased choice and control and more flexible use of funds; lower administration fees and more money to spend on services and supports; improved relations with service providers and the opportunity to select support staff. Participants wanted clear information and guidelines and support from their provider. While wanting to have more control and be empowered, few respondents noted concerns about possible risks. This finding raises questions about consumers' awareness of risks that are documented in the literature, and it challenges providers to balance risk management with facilitating independence and autonomy.

Challenges in the provision of digital technologies to elderly with dementia to support ageing in place: a case study of a Swedish municipality

PURPOSE

The aim of this paper is to identify structural problems and challenges for the delivery of digital technologies for ageing in place to elderly with dementia.

METHODS

To that end, I conducted a case study in a Swedish municipality.

RESULTS

The results showed that elderly with dementia are not exploiting their full potential of receiving help in the form of technology, since the four conditions of the Consumer Direction (Control and Direct services - Variety of digital technologies for ageing in place options - Information and Support - Participation in systems design) were met to a very low degree.

CONCLUSIONS

I propose that the municipality in question creates a proper knowledge-sharing platform so that occupational therapists are well informed about digital technologies for ageing in place, to allow them to provide accurate information and support to elderly with dementia, resulting in a possible increase in use of technology and subsequently support the empowerment goal of Consumer Direction. I also believe, according to the findings of this study, that the module of Information and Support should be treated as the most important condition for achieving increased Consumer Direction.Implications for rehabilitationElderly with dementia and their relatives do not receive sufficient information about digital technologies for ageing in place (DTAP). There is not enough information regarding the available options and their use. This often denies elderly with dementia and their relatives the services they are entitled.Occupational therapists knowledge about DTAP affects the variety of options presented to elderly with dementia and their subsequent use.Once a person is diagnosed with dementia, physicians tend to suggest medicinal solutions, overlooking the dissemination of DTAP information. Thus hindering their early access to DTAP.

Questioning "choice": A multinational metasynthesis of research on directly funded home-care programs for older people

In many developed contexts, home-care services have been overhauled with the intent of increasing control and flexibility for those using social and health services. This change is associated with providing funds directly to individuals, and sometimes their families and supports, to arrange at home-care assistance with the activities of daily living. Directly funded home-care programs, or "direct funding" (DF), are not value-neutral policy interventions, but complex and politicised tools for the enactment of care in contemporary times. In this qualitative metasynthesis, we consider 47 research articles published between 2009 and 2017 that explore various DF programs for older persons in the United Kingdom, Australia, and the United States to identify core concepts in the literature. We find that choice emerges as a central concern. We then assess the literature to explore the questions: How does the existing literature conceptualise choice, and the mechanisms through which choice is enhanced, in DF programs for older persons? How is choice, and the benefit of choice to older service users, understood in relevant studies? We argue that the concept of "choice" manifests as a normative goal with presumed benefits among the studies reviewed. Particularly when discussing DF for older people, however, it is essential to consider which mechanisms improve care outcomes, rather than focusing on which mechanisms increase choice writ large. In the case of DF, increased choice comes with increased legal responsibilities and often administrative tasks that many older people and their supports find burdensome. Furthermore, there is no evidence that choice over all elements of one's services is the mechanism that improves care experiences. We conclude by presenting alternative models of understanding care emerging from feminist and other critical scholarship to consider if we are, perhaps, asking the wrong questions about why DF is so often preferred over conventional home-care delivery.

The Tasks and Characteristics of Supportive Support Brokers

In the United States, under the Cash and Counseling or budget authority model of self-directed personal assistance where the participant manages his or her own services and supports, the Support Broker role was established to assist and coach the participant. The support broker role grew out of a person-centered planning process where focus groups and surveys helped ascertain what potential participants wanted to help them establish a self-directed alternative. But, despite this role being described in policy guidance from the Center for Medicare and Medicaid, little research has been conducted examining the functions, activities and usefulness of this position. This study draws on 76 ethnographic case studies with early Cash and Counseling participants, examines what participants and their caregivers actually saw the support broker doing, and looks at what the participants found helpful and less than helpful. Participants and family caregivers saw support broker duties as falling into four areas: Coaching, Problem Solving, Advocacy and Monitoring. Equally important was how the support broker performed these duties. Key aspects of quality included: Familiarity, Supportive Relationship, Proactive Engagement, Responsiveness, Knowledge and Cultural Friendliness. These findings can provide the basis for establishing quality indicators for self-direction.