Community professionals' management of client care: a mixed-methods systematic review

Caseload profiling in district nursing: a systematic literature review

This systematic literature review aims to identify and appraise current evidence to establish if caseload profiling (CP) provides a strategy to support district nurses to evidence and manage increasingly complex caseloads. A total of 17 studies where thematically synthesised and recurrent themes were identified and summarised under the headings of: defining caseload profiling; caseload profiling in the context of caseload management; workload analysis and its relationship to caseload profiling; potential impact of caseload profiling; and potential barriers to caseload profiling. The literature review showed CP is a robust method of articulating the complexity of care and practitioners could use it to help manage their own caseloads. However, the literature is mainly founded on expert opinion and further research is needed to strengthen the validity of the evidence.

Caseload management methods for use within district nursing teams: a literature review

Effective and efficient caseload management requires extensive skills to ensure that patients receive the right care by the right person at the right time. District nursing caseloads are continually increasing in size and complexity, which requires specialist district nursing knowledge and skills. This article reviews the literature related to caseload management with the aim of identifying the most effective method for district nursing teams. The findings from this review are that there are different styles and methods of caseload management. The literature review was unable to identify a single validated tool or method, but identified themes for implementing effective caseload management, specifically caseload analysis; workload measurement; work allocation; service and practice development and workforce planning. This review also identified some areas for further research.

Managing Waiting Times and Providing Equitable, Family-Centred Care: A Description of Four Key Initiatives from NHS Fife Child Health Occupational Therapy Service (2006–11)

Equity, timeliness and family-centredness are key dimensions of high-quality occupational therapy service delivery. This practice analysis reflects on practice-based initiatives to achieve these.

In 2006, the National Health Service Fife Child Health Occupational Therapy Service, in the United Kingdom, had extensive waiting times, which varied across the region, and high levels of service user dissatisfaction related to these. To address this, the service investigated ways to make better use of the existing resources and adopted the Care Aims framework, culminating in quality improvement initiatives. Key initiatives were: triaging new referrals, health promotion, care agreements with service users and extending the health care support worker's role. The main challenges encountered were staff anxiety and the expectations of both service users and other professionals. Important facilitators were dynamic leadership and well-motivated staff.

Following implementation, waiting times were reduced and are, at the time of writing, consistently less than 12 weeks. Anecdotal evidence suggests that service user satisfaction has improved.

Specifying content and mechanisms of change in interventions to change professionals' practice: an illustration from the Good Goals study in occupational therapy

BACKGROUND

It is widely agreed that interventions to change professionals' practice need to be clearly specified. This involves (1) selecting and defining the intervention techniques, (2) operationalising the techniques and deciding their delivery, and (3) formulating hypotheses about the mechanisms through which the techniques are thought to result in change. Descriptions of methods to achieve these objectives are limited. This paper reports methods and illustrates outputs from a study to meet these objectives, specifically from the Good Goals study to improve occupational therapists' caseload management practice.

METHODS

(1) Behaviour change techniques were identified and selected from an existing matrix that maps techniques to determinants. An existing coding manual was used to define the techniques. (2) A team of occupational therapists generated context-relevant, acceptable modes of delivery for the techniques; these data were compared and contrasted with previously collected data, literature on caseload management, and the aims of the intervention. (3) Hypotheses about the mechanisms of change were formulated by drawing on the matrix and on theories of behaviour change.

RESULTS

(1) Eight behaviour change techniques were selected: goal specified; self-monitoring; contract; graded tasks; increasing skills (problem solving, decision making, goal setting); coping skills; rehearsal of relevant skills; social processes of encouragement, support, and pressure; demonstration by others; and feedback. (2) A range of modes of delivery were generated (e.g., graded tasks' consisting of series of clinical cases and situations that become increasingly difficult). Conditions for acceptable delivery were identified (e.g., 'self-monitoring' was acceptable only if delivered at team level). The modes of delivery were specified as face-to-face training, task sheets, group tasks, DVDs, and team-based weekly meetings. (3) The eight techniques were hypothesized to target caseload management practice through eleven mediating variables. Three domains were hypothesized to be most likely to change: beliefs about capabilities, motivation and goals, and behavioural regulation.

CONCLUSIONS

The project provides an exemplar of a systematic and reportable development of a quality-improvement intervention, with its methods likely to be applicable to other projects. A subsequent study of the intervention has provided early indication that use of systematic methods to specify interventions may help to maximize acceptability and effectiveness.

Using shared goal setting to improve access and equity: a mixed methods study of the Good Goals intervention in children's occupational therapy

BACKGROUND

Access and equity in children's therapy services may be improved by directing clinicians' use of resources toward specific goals that are important to patients. A practice-change intervention (titled 'Good Goals') was designed to achieve this. This study investigated uptake, adoption, and possible effects of that intervention in children's occupational therapy services.

METHODS

Mixed methods case studies (n = 3 services, including 46 therapists and 558 children) were conducted. The intervention was delivered over 25 weeks through face-to-face training, team workbooks, and 'tools for change'. Data were collected before, during, and after the intervention on a range of factors using interviews, a focus group, case note analysis, routine data, document analysis, and researchers' observations.

RESULTS

Factors related to uptake and adoptions were: mode of intervention delivery, competing demands on therapists' time, and leadership by service manager. Service managers and therapists reported that the intervention: helped therapists establish a shared rationale for clinical decisions; increased clarity in service provision; and improved interactions with families and schools. During the study period, therapists' behaviours changed: identifying goals, odds ratio 2.4 (95% CI 1.5 to 3.8); agreeing goals, 3.5 (2.4 to 5.1); evaluating progress, 2.0 (1.1 to 3.5). Children's LoT decreased by two months [95% CI -8 to +4 months] across the services. Cost per therapist trained ranged from £1,003 to £1,277, depending upon service size and therapists' salary bands.

CONCLUSIONS

Good Goals is a promising quality improvement intervention that can be delivered and adopted in practice and may have benefits. Further research is required to evaluate its: (i) impact on patient outcomes, effectiveness, cost-effectiveness, and (ii) transferability to other clinical contexts.

The barriers and facilitators to routine outcome measurement by allied health professionals in practice: a systematic review

BACKGROUND

Allied Health Professionals today are required, more than ever before, to demonstrate their impact. However, despite at least 20 years of expectation, many services fail to deliver routine outcome measurement in practice. This systematic review investigates what helps and hinders routine outcome measurement of allied health professionals practice.

METHODS

A systematic review protocol was developed comprising: a defined search strategy for PsycINFO, MEDLINE and CINHAL databases and inclusion criteria and systematic procedures for data extraction and quality appraisal. Studies were included if they were published in English and investigated facilitators and/or barriers to routine outcome measurement by allied health professionals. No restrictions were placed on publication type, design, country, or year of publication. Reference lists of included publications were searched to identify additional papers. Descriptive methods were used to synthesise the findings.

RESULTS

960 papers were retrieved; 15 met the inclusion criteria. Professional groups represented were Physiotherapy, Occupational Therapy, and Speech and Language Therapy. The included literature varied in quality and design. Facilitators and barriers to routine outcome measurement exist at individual, managerial and organisational levels. Key factors affecting professionals' use of routine outcome measurement include: professionals' level of knowledge and confidence about using outcome measures, and the degree of organisational and peer-support professionals received with a view to promoting their work in practice.

CONCLUSIONS

Whilst the importance of routinely measuring outcomes within the allied health professions is well recognised, it has largely failed to be delivered in practice. Factors that influence clinicians' ability and desire to undertake routine outcome measurement are bi-directional: they can act as either facilitators or barriers. Routine outcome measurement may only be deliverable if appropriate action is taken at individual therapist, team, and organisational levels of an organisation.

Community mental health nurses, caseloads, and practices: a literature review

Deinstitutionalization, and more recently, earlier discharges from psychiatric inpatient units, have created and intensified the need for case management in community mental health. Nurses have been at the forefront of providing this case management. This literature review provides a synthesis of research and policy on the contribution of mental health nurses to community case management. The focus of this review is on the proportion of case management that mental health nurses undertake, the caseloads of case managers, and the interventions that mental health nurses most frequently perform in the community. The professional compositions of mental health case management workforces have been associated with economic imperatives, professional priorities, and the choice of case management models. The influence of mental health nurses in the case management workforce is particularly strong in the U.K. and Australia, but less so in the U.S.A. where social workers and people without mental health qualifications perform similar roles. Although heavy caseloads seem to be common among case managers, the research in this area is quite weak. The interventions that mental health nurses perform most often include case management (e.g., coordinating care), counselling, and medication management. Caring for the physical health of consumers might often be overlooked.

Use of dependency and prioritization tools by clinical nurse specialists in palliative care: an exploratory study

AIMS

The principal aim was to assess the utility of three needs assessment/dependency tools for use in community-based palliative care services. Specific objectives were to assess a sample of patients receiving specialist palliative care community nursing using these tools, to assess the predictive ability of each tool, and to explore the utility of prioritizing and measuring patient dependency from a clinical nurse specialist (CNS) perspective.

METHOD

In phase 1, 22 community-based CNSs completed the Vale prioritization tool for all patients visited during a 3-month period (n=162). They also completed either the Graves and Payne (2007) or the Birch et al (1997) dependency tool after each visit. In phase 2 a focus group (n=8) and two one-to-one interviews with CNS participants explored the perceived utility of all three tools.

RESULTS

The Vale prioritization tool appeared to be the most useful for prioritizing patient need and managing workload. Statistical analysis highlighted minimal differences between the two dependency tools, neither of which predicted length of visit. Three themes were identified from phase 2: difficulties with routine administration, points of divergence between the two dependency tools, and workload concerns.

CONCLUSION

While the Vale prioritization tool emerged as the most useful, the findings raise questions about the overall utility and practical application of these kinds of tools with community-based palliative care patients. Further research is needed to identify/develop, adapt, and evaluate appropriate, setting-specific dependency tools for use with this population.

Beliefs about responsibilities, the aims of therapy and the structure of the therapy process: a qualitative study of caseload management issues in child health occupational therapy

BACKGROUND

Individual therapists' behaviour contributes to overall caseload management in therapy services. Therapists' caseload management (i.e. actions in relation to assessment, treatment and discharging) is likely to relate to their beliefs about caseload management; it may be possible to change therapists' caseload management by changing their beliefs. This study explored children's occupational therapists' beliefs about caseload management with a view to designing a caseload management intervention.

METHODS

Twenty-five therapists from six NHS Scotland Health Boards were interviewed using a semi-structured format. Interviews were transcribed verbatim, and the interview transcripts were analysed for emerging themes. A proportion of transcripts were independently read and coded, and the themes were validated through critical discussion.

RESULTS

Key issues emerged concerning therapists' beliefs about their responsibilities, the aims of therapy and the structure of the therapy process. Therapists expressed a strong sense of professional duty/responsibility, but the interpretations of what this duty/responsibility was differed between therapists. For example, therapists expressed highly contrasting beliefs about the goals and purpose of therapy and the ways in which therapy processes should be structured. Some therapists promoted an approach structured around clients' goals, while others focused more on relationship building.

CONCLUSIONS

Therapists' beliefs about caseload management differ considerably; these differences could translate to variation in therapists' intentions and behaviours. Implications for practice, policy and future research were identified, as were implications for the way clinicians' caseload management is theorized.