Care co-ordination and key worker schemes for disabled children: results of a UK-wide survey

Psychosocial support for families of children with neurodisability who have or are considering a gastrostomy: the G-PATH mixed-methods study

Background

Evidence reviews recommend consistent and structured support for children with neurodisability and their caregivers in care pathways in which professionals recommend a gastrostomy feeding tube. To date, and to our knowledge, no research has shown how these recommendations have been implemented.

Objectives

The objectives were to describe different exemplar models of psychosocial support and provide an estimate of their resources and costs.

Design

This was a mixed-methods study involving (1) a web-based survey, (2) a qualitative, collective case study of psychosocial support provision in four services and (3) an estimate of costs and preference through a willingness-to-pay study.

Setting

Four service configurations in different locations in England and Scotland.

Participants

Participants were staff who responded to a survey (n = 67) and interviewees (staff, n = 58; parents/children, n = 29).

Findings

Psychosocial support was rarely formalised or documented; it was delivered by different members of the multidisciplinary team, rather than by designated staff, and it was often integrated into appointments dominated by clinical care. Parents expressed different needs for support but reported little opportunity to discuss emotional aspects. Psychologists were not routinely involved and, in general, families were underserved by psychosocial services. Professionals constructed families’ need for psychosocial support in terms of their own roles and the management of risk. Mechanisms for integrating and delivering support were identified, including models of care that linked community and tertiary health services and integrated health and education through pooled budgets. Although generally valued by both staff and parents, peer-to-peer parent support was not consistently offered. Barriers included concerns about confidentiality and appropriately matching parents. Parents participated as members of a feeding committee at one site. Three analytical constructs described the provision of psychosocial support: ‘hidden work’, expressing emotional vulnerability and negotiations around risks and values. The cost-of-support study found that there was a mean of 2.25 appointments (n = 8 parents or carers) over the previous 12 months. The cost of health-care professionals’ time spent on providing psychosocial support ranged from £0.00 to £317.37 per child per year, with an average cost of £76.42, at 2017 prices. In the willingness-to-pay study the median rank of enhanced support, involving the opportunity to see a psychologist and parental peers, was significantly higher than that of usual care (n = 96 respondents, both carers and professionals, who completed rating of the service; p < 0.001).

Limitations

It proved difficult to disseminate a national survey, which resulted in a small number of returns, and to cost the provision of psychosocial support, which we designated as ‘hidden work’, owing to the lack of recording in clinical systems. Moreover, estimates were based on small numbers.

Conclusions

Parent interviews and the willingness-to-pay study demonstrated a preference for enhanced psychosocial support. The study suggests that there is a need for services to formally assess families’ needs for psychosocial support to ensure that provision is planned, costed and made explicit in care pathways. Personalised interventions may assist with the targeting of resources and ensuring that there is an appropriate balance in focus on both clinical care and psychosocial support needs in relation to and following treatment.

Future work

More work is needed to develop tools to assess families’ needs for psychosocial support and the effectiveness of training packages to strengthen team competency in providing support.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 38. See the NIHR Journals Library website for further project information.

Role-related stress and perceptions of the keyworker role among professionals supporting adults with intellectual disabilities

Purpose

Individuals with intellectual disabilities who are users of day and residential services will often be assigned at least one “keyworker”, a staff member who is expressly responsive to their needs and responsible for co-ordinating services with them. Keyworkers are often given their role because it is a norm in their organisation. However, given the emotionally intensive workload involved in co-ordinating care for a single individual, little attention is given to the potential stress burden of being a keyworker. The paper aims to discuss this issue.

Design/methodology/approach

A cross-sectional survey study was conducted of professionals’ perceptions of the keyworker role and of levels of workplace well-being. The authors first examine differences between keyworkers and their colleagues along measures of role perception and well-being. The authors then present a new measure of keyworkers’ duties and boundaries (Key-DAB) capturing perceptions of the keyworker role by keyworkers and other staff. The measure was administered to a sample of staff (n=69) from an Irish provider of services for adults with intellectual disabilities. Alongside the new scale, the authors administered established measures of workplace well-being and locus of control (LoC) to examine construct validity and assess if perception of keyworking could be related to stress.

Findings

Some differences were detected between keyworkers and non-keyworkers: keyworkers had more internally oriented LoC and experienced lower work pressure than non-keyworking colleagues. The Key-DAB measure possessed favourable psychometric properties, including high internal reliability. External validity was also shown as keyworkers’ scale scores were related to LoC and to role demands. Results suggested: that keyworkers who are clear about what is expected of the keyworker are more satisfied with their role and perceive keyworking as beneficial to them; that role ambiguity and role conflict can undo these potential benefits and render the keyworker’s role a potentially hazardous one.

Originality/value

The authors recommend that employers provide clear guidelines and explicit training to keyworkers and suggest that the measures may be effective tools for ongoing assessment of keyworkers’ role clarity.

The Role of Care Coordinator for Children with Complex Care Needs: A Systematic Review

Introduction:

This systematic review seeks to identify the intended components of the role of care coordinator for children with complex care needs and the factors that determine its composition in practice.

Theory and methods:

The initial search identified 1,157 articles, of which 37 met the inclusion criteria. They were quality assessed using the SIGN hierarchy of evidence structure.

Results:

Core components of the role include: coordination of care needs, planning and assessment, specialist support, emotional support, administration and logistics and continuing professional development. Influencing factors on the role include the external environment (political and socio-economic), the internal environment (organisational structure and funding protocols), the skills, qualifications and experience of the coordinator, the family circumstances and the nature of the interaction between the care coordinator and the family.

Discussion:

The lack of consistent terminology creates challenges and there is a need for greater consensus on this issue. Organisations and healthcare professionals need to recognise the extent to which contextual factors influence the role of a care coordinator in practice and plan accordingly. Despite evidence that suggests that the role is pivotal in ensuring that care needs are sustained, there remains great variability in the understanding of the role of a care coordinator for this population.

Conclusions:

As the provision of care increasingly moves closer to home there is a need for greater understanding of the nature and composition of the interaction between care coordinators and families to determine the extent to which appropriate services are being provided. Further work in this area should take into consideration any potential variance in service provision, for example any potential inequity arising due to geographic location. It is also imperative, where appropriate, to seek the views of children with complex care needs and their siblings about their experiences.

What do nurses think they are doing in pre-school autism assessment?

This study reports on the perspective of all the specialist nurses in community paediatric teams in one NHS trust on their role in pre-school autism assessment. Kim's critical reflective inquiry research method ( Kim, 1999 ) was adapted through the inclusion of the researcher as a participant. Participants reflected on the nursing beliefs and values they hold in common, and on their actions in practice. The study found that the beliefs and values held by these nurses, and their intention to offer holistic nursing delivered through a professional relationship of care, correlated with the kind of care that parents have said families need, and make a unique contribution to team assessment.

Service characteristics as predictors of parents' perceptions of child rehabilitation outcomes

Medical rehabilitation arranged by the Social Insurance Institution of Finland is provided for children with severe disabilities. The study aimed to find out which service characteristics were associated with perceived outcomes of rehabilitation. Parents whose children had participated in rehabilitation (n = 496) responded to a mail questionnaire that included questions on service characteristics and possible outcomes. Based on factor analysis, four outcome variables were formed. Logistic regression analysis was used to identify the particular service characteristics that were associated with the perceived outcomes. The family's participation in rehabilitation planning and the child's willingness to participate in rehabilitation activities were associated with good outcomes. Having a contact person for the rehabilitation process predicted child and family empowerment outcomes. The results emphasize the significance of establishing a good partnership between the professionals and the family; of developing the contents of the rehabilitation program, so that they motivate the child, and of organizing service coordinators for each family.

Parents' Perspectives of Cleft Lip and/or Palate Services: A Qualitative Interview

The study aimed to explore in depth the perspectives of parents about their child's cleft services. Purposive and theoretical sampling produced a diverse sample of mothers and fathers with children aged 20 weeks to 21 years. Parents were recruited from a specialist cleft center in the U.K. Qualitative, in-depth, face-to-face interviews were carried out with 35 parents. Interviews were audio-recorded, transcribed, and analyzed using grounded theory to identify salient data categories. Findings revealed that parents' positive views about services rested on their perceptions of cleft-care practitioners as competent and trustworthy, possessing highly developed communication skills and the ability to provide continuity of care to families. At the same time, some mothers and fathers identified unmet support needs relating to information delivery and content as well as the coordination of services across the treatment course. More individualized information about treatment was desired; in particular, some parents had incomplete information about their child's surgical procedures, associated risks, and postsurgical recovery. Parents wanted better coordination of services with regard to communication about surgical cancellations, a child's transition to adult services, and having a key professional to link with throughout their child's treatment course. Routine assessments to gauge parents' needs could be built into cleft-care pathways so that more individualized information and support might be delivered to families in more consistent ways over long-term treatment.

Key working for families with young disabled children

For families with a disabled child, the usual challenges of family life can be further complicated by the need to access a wide range of services provided by a plethora of professionals and agencies. Key working aims to support children and their families in navigating these complexities ensuring easy access to relevant, high quality, and coordinated care. The aim of this paper is to explore the key worker role in relation to “being a key worker” and “having a key worker”. The data within this paper draw on a larger evaluation study of the Blackpool Early Support Pilot Programme. The qualitative study used an appreciative and narrative approach and utilised mixed methods (interviews, surveys and a nominal group workshop). Data were collected from 43 participants (parents, key workers, and other stakeholders). All stakeholders who had been involved with the service were invited to participate. In the paper we present and discuss the ways in which key working made a difference to the lives of children and their families. We also consider how key working transformed the perspectives of the key workers creating a deeper and richer understanding of family lives and the ways in which other disciplines and agencies worked. Key working contributed to the shift to a much more family-centred approach, and enhanced communication and information sharing between professionals and agencies improved. This resulted in families feeling more informed. Key workers acted in an entrepreneurial fashion, forging new relationships with families and between families and other stakeholders. Parents of young disabled children and their service providers benefited from key working. Much of the benefit accrued came from strong, relational, and social-professional networking which facilitated the embedding of new ways of working into everyday practice. Using an appreciative inquiry approach provided an effective and relevant way of engaging with parents, professionals, and other stakeholders to explore what was working well with key working within an Early Support Pilot Programme.

Family-centred service coordination in childhood health and disability services: the search for meaningful service outcome measures

BACKGROUND

Potential service outcome measures were tested for their utility in the assessment of the quality of 'family centred' service coordination in the provincial network of children's disability services in Manitoba, Canada.

METHODS

This study is based on in-home survey data provided by 103 mothers at 6 and 18 months following assignment of a 'dedicated' service coordinator. Service outcome indicators included measures of parent self-esteem, parenting stress, family functioning and the need for family support resources.

RESULTS

Hierarchical regression analyses showed no relationship between level of quality of family-centred service coordination and standardized psychosocial measures of parent and family functioning. However, family centredness of service coordination was found to predict significant reduction in level of family need for psychosocial support resources after 18 months of contact with a service coordinator.

CONCLUSIONS

Outcome measures that are focused on specific and tangible results of service coordination appear to be of higher utility in service quality assessment than are more global, standardized measures of parent and family functioning.

Involving families who have deaf children using a Family Needs Survey: a multi-agency perspective

BACKGROUND

Meeting the needs of deaf children and their families is multidisciplinary. Models of multi-agency working are diverse, and there is little evidence on outcome for family and child. Effective collaboration is an essential part of multi-agency working, and how this is achieved is an area that warrants research.

METHODS

An approach was developed to identify family needs using a need identification tool called a Family Needs Survey (FNS) in conjunction with a multi-agency meeting. The FNS was introduced in a pilot study to involve parents of deaf children with services and to identify their needs from their perspective.

RESULTS AND CONCLUSIONS

A clear pathway was determined for application of the FNS. A model of multi-agency working was developed that involves families directly with different services at one time. Outcomes were measured by uptake of the FNS, parental attendance at multi-agency meetings, and completion of a parent evaluation questionnaire. Discussion of the FNS at a multi-agency meeting facilitates communication between professionals and between professionals and parents. There is some evidence that the FNS may be a useful tool. The majority of parents completed a FNS before multi-agency meetings and have indicated they are happy to share the information with other professionals.

The costs of key worker support for disabled children and their families

BACKGROUND

Key workers provide a single point of contact for disabled children and their families, supporting them and facilitating access to other services. Key worker services appear to generate good outcomes for families and provision is encouraged through central government policy. Recent increases in key worker provision have been accompanied by a proliferation of delivery models yet there is very little information on their costs.

METHODS

Within a study identifying which service characteristics generate good outcomes for families, unit costs for seven key worker services were estimated. Informed by economic theory, the estimates drew on data from managers, finance departments and other publicly available sources. Data on the frequency and duration of contact with key workers were obtained from families and combined with the service-specific unit costs to arrive at the contact cost per family. The variations in the costs of supporting families were explored.

RESULTS

On average, key worker contact with disabled children and their families cost pound 151 over a 3-month period. Contact costs were found to vary with the level of the child's disability and the number of role aspects that key workers performed. This latter variable was associated with improved outcomes.

CONCLUSION

The low response rate to the questionnaire and absence of data on the costs of other elements of the families' support packages may limit generalization from this study. Even so, such findings can help inform managers and planners about allocation of their scarce resources. Good-quality services appear to cost more but the relationship between cost, quality and outcomes is not a simple one.

Rules and resources: a structuration approach to understanding the coordination of children's inpatient health care

AIM

This paper presents findings from a multi-method study exploring the process of care coordination in children's inpatient health care.

BACKGROUND

Existing work on care coordination is typified by "black-box" type studies that measure inputs to and outcomes of care coordination roles and practices, without addressing the process of coordination.

METHOD

Using questionnaires, interviews and observation to collect data in multiple sites in the United Kingdom and Denmark between 1999 and 2005, the study gathered the perceptions of staff and compared these with observed practice. Giddens' structuration theory was used to provide an analytical and explanatory framework.

FINDINGS

Current care coordination practice is diverse and inconsistent. It involves a wide range of clinical and non-clinical staff, many of whom perceive a lack of clarity about who should perform specific coordination activities. Staff draw upon a wide range of different material and non-material resources in coordinating care, the use of which is governed by largely tacit and informal rules.

CONCLUSIONS

Care coordination can be usefully conceptualized as a "structurated" process--one that is continually produced and reproduced by staff using rules and resources to "instantiate" or bring about care coordination through action. Potentially negative implications of this are manifested in diversity and inconsistency in care coordination practice. However, positive aspects such as the opportunity this provides to tailor care to the needs of the individual patient can be realized.

Key worker services for disabled children: the views of staff

Provision of 'key workers' for disabled children and their families, working across health, education, and social services, has been recommended in the Children's National Service Framework. This study investigated the views of staff of key worker services concerning the organisation and management of the services. Interviews were carried out with key workers (N=50), managers (N=7) and members of multi-agency steering groups (N=32) from seven key worker services in England and Wales. A response rate of 62% was obtained. Major themes emerging from the interviews were identified, a coding framework was agreed upon, and data were coded using the qualitative data analysis programme Max QDA. Results showed that although the basic aims of the services were the same, they varied widely in the key workers' understanding of their role, the amount of training and support available to key workers, management and multi-agency involvement. These factors were important in staff's views of the services and inform recommendations for models of service.

Service integration and co-ordination: a framework of approaches for the delivery of co-ordinated care to children with disabilities and their families

This article clarifies the nature of 'service integration' and 'service co-ordination' and discusses how these aspects relate to the fundamental goal of providing co-ordinated care for children with disabilities and their families. Based on a review of the service delivery literatures in the fields of health, social services and rehabilitation, a framework is presented that outlines the scope of the co-ordination-related functions and activities encompassed in three common types of approaches to the delivery of co-ordinated care. These are a system/sector-based service integration approach, an agency-based service integration approach and a client/family-based service co-ordination approach. The functions outlined in the framework include aggregate-level planning of services (designed to map out the scope and plan for service provision in a community or geographical area), administrative functions (designed to ensure wise and equitable access to resources) and client-specific service delivery functions (designed to link clients/families to needed services). The framework is a tool that can be used to support policy making and decision making with respect to the design of efforts to provide co-ordinated care. It provides information about commonly used approaches and the essential elements of these approaches, which can be used in making choices about the scope and nature of an approach towards service integration/co-ordination.

Decision-making in community-based paediatric physiotherapy: a qualitative study of children, parents and practitioners

Approaches to practice based on partnership and shared decision-making with patients are now widely recommended in health and social care settings, but less attention has been given to these recommendations in children's services, and to the decision-making experiences of non-medical practitioners and their patients or clients. This study explored children's, parents' and practitioners' accounts of shared decision-making in the context of community-based physiotherapy services for children with cerebral palsy. Semi-structured interviews were conducted with 11 children with cerebral palsy living in an inner city area of northern England, and with 12 of their parents. Two focus groups were conducted with 10 physiotherapy practitioners. Data were analysed using the constant comparative method. When asked explicitly about decision-making, parents, children and practitioners reported little or no involvement, and each party saw the other as having responsibility for decisions. However, when talking in more concrete terms about their experiences, each party did report some involvement in decision-making. Practitioners' accounts focused on their responsibility for making decisions about resource allocation, and thereby, about the usefulness and intensity of interventions. Parents indicated that these practitioner-led decisions were sometimes in conflict with their aspirations for their child. Parents and children appeared to have most involvement in decisions about the acceptability and implementation of interventions. Children's involvement was more limited than parents'. While parents could legitimately curtail unacceptable interventions, children were mostly restricted to negotiating about how interventions were implemented. In these accounts the involvement of each party varied with the type of issue being decided and decision-making appeared more unilateral than shared. In advocating shared decision-making, greater understanding of its weaknesses as well as its strengths, and greater clarity about the domains that are suitable for a shared decision-making approach and the roles of different parties, would seem a helpful step.

Care and support needs of children and young people with cancer and their parents

The importance of psychosocial support services for children with cancer and their families is recognised but evaluation of such services is less well developed with little information available about different patterns of provision. This paper provides an overview of psychosocial support children and their families in the UK receive during and after treatment. It reports the results of a postal survey of 303 families, within which parents and children identified their satisfaction with support services and also areas of unmet need. Satisfaction was identified in a range of areas, including medical information and support from nurses and social workers. However, areas of unmet need were also highlighted, especially age appropriate facilities, emotional support and information in different formats. Although British government policy currently seeks to develop standards and guidelines of care throughout the National Health Service, this paper demonstrates that there is still a need to develop psychosocial support services and work towards recently established guidelines in order to ensure that families receive flexible but equitable packages of care and support, wherever treatment is received.

Nurses', midwives' and health visitors' involvement in cross-boundary working within child health services

BACKGROUND

Cross-boundary working is a key policy objective. Cross-boundary working provides the foundation for high quality provision across child health services and is imperative for an effective child protection system and the support of children and young people with health needs.

METHODS

Two participative conferences were attended by 113 stakeholders utilizing the World Café focus group method. Most (87%) of the sample were nurses, midwives or health visitors.

RESULTS

Many examples of cross-boundary working were identified across the different areas of practice. Remarkably few transdisciplinary examples were identified in contrast to the number of inter-agency examples. Intra-organizational boundaries across the health service were also noted.

CONCLUSIONS

Considerable cross-boundary working was reported but transdisciplinary working is not yet well established across all areas of child health provision.

Survey of paediatric case management practices in Australia for children and young people with acquired brain injury (ABI)

AIM

To investigate the characteristics of paediatric acquired brain injury (ABI) case managers and their organizations in Australia, and to determine the ways in which case managers deliver their service, maintain professional development and evaluate outcomes.

METHODS

Postal survey of 57 known paediatric ABI case managers working at 24 separate organizations in Australia.

RESULTS

Out of 40 questionnaires returned (70%), the majority of respondents had been providing case management for over 5 years (55%). Co-ordination of services was ranked the most important component of case management, with services most frequently delivered by telephone. Evaluation of case management outcomes was reported by only 52% of the case managers. Whilst the majority of case managers had received some form of training (83%), this varied widely from informal in-house training, to workshops run by insurance companies and government agencies.

DISCUSSION

This survey provides information about current case management practices for children with ABI in Australia. Detailing what case managers do is a first step towards developing controlled research designs which are required to demonstrate whether case management is effective in terms of clinical outcomes and cost-benefit.