Thank you, Mr. Kerr and the session organizers, for inviting me as a representative of McMaster University, Hamilton, Ontario, to briefly address today's topic on case management.
I would like to commend you on your study of transformation Initiatives at Veterans Affairs Canada, which includes your five themes—reducing complexity, overhauling service delivery, strengthening partnerships, sustaining the new Veterans Charter of October 2011, and adapting to changing demographics—all of which look as if they're very client-focused and will require the element of case management.
In light of this and as a focus for today's session, I would like to provide my comments under four sections: first, history; second, the McMaster University case management program; third, examples of home care—they're interspersed throughout the presentation—and finally, research.
In terms of history, case management in homes began in England in 1601 under social welfare legislation. In the United States, case management rehabilitation programs were started in the 20th century. George Welch is considered the father of U.S. modern case management, and really, the focus was controlling the spiralling costs of health care.
In 2000, approximately 68% of an estimated 80,000 case managers in the U.S.A. worked in insurance and rehabilitation, so 32% worked someplace else. The genius of case management is its extraordinary flexibility and endurance, under the premise that case management provides an individual with the opportunity to reach her optimum level of wellness, functional capacity, and living arrangements. Case management is a collaborative, client-driven process that focuses on quality health care and social support, through the effective and efficient use of resources.
Case management achieves client wellness, wholeness, and autonomy through respect, communication, advocacy, service identification, coordination, integrated planning, reflective evaluation, and research-based approaches.
Catherine Mullahy, one of the champions of case management several years ago, described case management as the only profession that looks at the gestalt. Certainly at McMaster University we take the focus it needs.
McMaster University's certificate program offers an online program to all parts of Canada. We have students from British Columbia, the east coast, the Northwest Territories, and outside Canada. There are five core courses, and they are completed in five years.
We begin with topics such as history: background, definitions. We focus on the legislation and regulations, which look at where the case manager works, such as B.C, the Northwest Territories, or Ontario. We add items of interest such as the Drummond report, where they spoke of case management and the systems navigators, and that all regions should have that quarterback.
The standards of practice, the competencies, roles, functions, processes, and reflective practice are other areas of case management. The CCAC offers as an example the electronic tools, scores, and algorithms that give an assessment of case management with key outcome indicators in order for the case manager to provide care in the home including: nursing, personal support, physiotherapy, OT, speech-language pathology, social work, nutritional counselling, and medical supplies and equipment.
They also have things such as medication reviews for the elderly in terms of risk management and safety. The case managers are considered the care connectors; they match clients in need with primary care providers. We look closely at the models of case management—and there are many—and we go through those details. A more recent example is an integrated and intensive model that the CCACs are looking at, which looks at clients who are high-complex or “chronic community-independent short-stay”. The model includes a high-risk need with fewer clients per case manager.
They also have an integrated client-care project, a multi-year initiative that looks at specific populations including: wound care, palliative care, frail seniors, chronic disease management, and medically complex children. The model is the work of Michael Porter from Harvard, and it looks at value-based care with coordination, integration, and specialization as the key features.
Other things they have are the rapid-response nurse, who is very solution-focused, for those who need attention and are complex in their transitioning from hospital to home.
Along with the models, we also teach the topologies of case management. One of the key ones that is featured is the problem-based topology. Again, in terms of the application, they are using that as a model in CCACs with integrated intensive models, along with a populated-based focus, which looks at seniors, child and youth, and palliative.
Other topics we include in our program are the elements of personhood, which is such an important feature in terms of individuality, wholeness, and integrity; and ethical issues in terms of ethical dilemmas, decision-making; and ethical, legal, and financial issues in case management. We view cultural competencies in looking at adequate health and social services without facing any discrimination.
The impact of mental health issues is another area. We see in many of the CCACs in Ontario, if the client has a primary diagnosis of mental health issues, that is assigned to a specialized case manager because of the complexity of that care. We do mention things, such as the Mental Health Commission of Canada's introduction of Changing Directions, Changing Lives, the first mental health strategy for Canada.
Other areas we focus on are the social determinants of health and their application in terms of case management; collaboration between sectors—public health, primary care, community care—and systems thinking and navigation. Because case management is a dynamic process, case managers act as a systems navigator, facilitator, in trying to balance the provision of services to produce optimal health, independence, client satisfaction, and fiscal responsibility.
I'd like to end with research. We do offer another course linking case management to policy, education, and evidence-based research to influence policy and program development. We encourage case managers to continue their professional development and to familiarize themselves with best practice and its application.
The most recent study being done is regarding case management. You can have all the tools, algorithms, and scores in the world, but when you are looking at teams and working together in an integrated specialized way, you have to have that excellent skill, that expert case manager. The study is a qualitative, phenomenological research that looks at the experience of experienced case managers. It's called “The Nature of Insight: Case Management”. It will be completed this summer.