A new kind of gatekeeper: The increasing prevalence of Advanced Practice Nurses as case managers in US hospitals.

Case management is a representation of managed care, cost-containment organizational practices in healthcare, where managed care and its constitutive parts are situated against physician autonomy and decision-making. As a professional field, case management has evolved considerably, with the role recently taken up increasingly by Advanced Practice Nurses in various health care settings. We look at this evolution of a relatively new work task for Advanced Practice Nurses using a countervailing powers perspective, which allows us to move beyond discussions of case management effectiveness and best practices, and draw connections to trends in the social organization of healthcare, especially hospitals. We evaluated organizational (hospital-level) and environmental (county and state-level) characteristics associated with hospitals' use of Advanced Practice Nurses as case managers, using data from U.S. community acute care hospitals for 2016-2018, collected from three data sources: American Hospital Association annual survey (AHA), Centers for Medicare and Medicaid Services (CMS), and Area Resource File. Among organizational characteristics, we found that hospitals that are a part of established Accountable Care Organizations (OR = 2.55, p = 0.009; 95% CI = 1.26-5.14) and those that serve higher acuity patients, as indicated by possessing a higher Case Mix Index (OR = 1.32, p = 0.001; 95% CI = 1.13-1.55), were more likely to use Advanced Practice Nurses as case managers. Among environmental characteristics, having higher local Advanced Practice Nurses concentrations (OR = 1.24, p < 0.001; 95% CI = 1.11-1.39) was associated with hospital Advanced Practice Nurses case management service provision. Beyond the health impacts of Covid-19, its associated recession is placing families, governments and insurers under unprecedented financial stress. Governments and insurers alike are looking to reduce costs anywhere possible. This will inevitably result in increasing amounts of managed care, and decreasing reimbursements to hospitals, likely resulting in higher demand for APRN patient navigators.

Accuracy of case managers in estimating intelligence quotients and functional status of people experiencing homelessness.

Adults who are homeless experience high rates of health conditions and psychological distress, including low IQ and functional status. Resources are available to help these individuals, but provision of support is often contingent upon the identification of a known disability. In this context, we examined case managers' (CMs') subjective estimates of IQ and functional status in 77 adult residents of an urban homeless shelter. Participants completed objective measures of IQ and functional capacity. CMs overestimated IQs of lower IQ (IQ < 90) participants, correctly estimated IQs of average IQ (IQ = 90-110) participants, and underestimated IQs of higher IQ (IQ > 110) participants. CMs correctly identified 2 out of 8 participants meeting criteria for intellectual disability and 4 out of 16 participants with impaired functional status. These findings suggest that subjective evaluations of IQ and functional status are prone to a central tendency bias, leading CMs to overlook clients who are in need of assistance. Consequently, the objective measurement of IQ and functional status in homeless shelters is highly recommended. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Senior manager decision-making and interactions with frontline staff in intellectual disability organisations: A Delphi study.

Very little is known of the activities of the most senior managers in organisations providing social care in the community to people with intellectual disabilities. Yet the importance of the focus and activities of senior managers in directing and supporting staff practice and staff experiences is likely to be central to an organisation's functioning and support provided for staff and service users. This study employed Delphi methodology with a panel of 11 senior managers, mostly chief executives, managing small to very large organisations providing support for people with intellectual disabilities, in the UK. Answering three rounds of questions, senior managers described their face-to-face and non-face-to-face contacts with staff and decision-making. Narrative data were subject to quantitative and thematic analysis. In the last round, themes were subject to quantitative analysis. Most contacts between senior managers and staff were in formal structured contexts and all managers used social media to promote the organisations' ambitions regarding good practice. The panel focused upon accessing and understanding the informal aspects of their organisations and staff factors. Decisions were both short-term reactive and long-term strategic and an effort to link these was felt to improve organisational functioning. A framework for understanding senior managers' activities emerged showing two sources of demands and opportunity, extra-organisational focused upon meeting legal and regulatory demands and intra-organisational focused upon understanding and influencing informal staff practices/experiences and cultures within their organisations.

Experiences of nurse case managers within a central discharge planning role of collaboration between physicians, patients and other healthcare professionals: A sociocultural qualitative study.

AIMS AND OBJECTIVES: To gain knowledge of nurse case managers' experiences within the German acute care context of collaboration with patients and physicians in a discharge planning role; further to learn about patients' assignment to the management of the nurse case managers; and explicitly to explore critical incidences of interactions between nurse case managers, patients and healthcare practitioner in discharge planning to understand the factor that contributes to effective collaboration. BACKGROUND AND PURPOSE: The defined role of nurse case managers in many contexts is a patient-centred responsibility for a central task of discharge management of patients with complex physical and social needs. Some studies have indicated that the general impact of the role reduces readmission rates. Given the necessity to work interprofessionally to achieve a safe discharge, little is known about how nurse case managers achieve this collaboratively. METHODS: A qualitative case study within a German teaching hospital of nurse case managers (N = 8). Data were collected through semi-structured interviews prompted by a critical incident technique and rigorously analysed through the lenses of sociocultural theory. RESULTS: Consistent object being worked upon was a safe and effective discharge from hospital with a focus on patient advocacy. Significant themes were a self-value or recognition by others of professional expertise, reciprocal value on the capabilities of others thorough relational expertise and negotiation with patients and an identification of case trajectories. CONCLUSION: More continuity of nurse case managers' care and management, clarity of role and transparency to peers, physicians and other professionals would be beneficial in ensuring appropriate referral of complex patients to nurse case managers responsibility. RELEVANCE TO CLINICAL PRACTICE: Clearer role description and benefit realisation of the nurse case managers could be achieved by interventions that are interprofessional and focus on the tasks that matter from a collaborative perspective. This could lead to refinement of available indicators and policy developments.

Case Managers for High-Risk, High-Cost Patients as Agents and Street-Level Bureaucrats.

Case management programs often designate a nurse or social worker to take responsibility for guiding care when patients are expected to be expensive or risk a major decline. We hypothesized that though an intuitively appealing idea, careful program design and faithful implementation are essential if case management programs are to succeed. We employed two theory perspectives, principal-agent framework and street-level bureaucratic theory to describe the relationship between program designers (principals) and case managers (agents/street-level bureaucrats) to review 65 case management studies. Most programs were successful in limited program-specific process and outcome goals. But there was much less success in cost-saving or cost-effectiveness-the original and overarching goal of case management. Cost results might be improved if additional ideas of agency and street-level theory were adopted, specifically, incentives, as well as "green tape," clear rules, guidelines, and algorithms relating to resource allocation among patients.

CollAborative care for Screen-Positive EldeRs with major depression (CASPER plus): a multicentred randomised controlled trial of clinical effectiveness and cost-effectiveness.

BACKGROUND: Depression in older adults is common and is associated with poor quality of life, increased morbidity and early mortality, and increased health and social care use. Collaborative care, a low-intensity intervention for depression that is shown to be effective in working-age adults, has not yet been evaluated in older people with depression who are managed in UK primary care. The CollAborative care for Screen-Positive EldeRs (CASPER) plus trial fills the evidence gap identified by the most recent guidelines on depression management. OBJECTIVES: To establish the clinical effectiveness and cost-effectiveness of collaborative care for older adults with major depressive disorder in primary care. DESIGN: A pragmatic, multicentred, two-arm, parallel, individually randomised controlled trial with embedded qualitative study. Participants were automatically randomised by computer, by the York Trials Unit Randomisation Service, on a 1 : 1 basis using simple unstratified randomisation after informed consent and baseline measures were collected. Blinding was not possible. SETTING: Sixty-nine general practices in the north of England. PARTICIPANTS: A total of 485 participants aged ≥ 65 years with major depressive disorder. INTERVENTIONS: A low-intensity intervention of collaborative care, including behavioural activation, delivered by a case manager for an average of six sessions over 7-8 weeks, alongside usual general practitioner (GP) care. The control arm received only usual GP care. MAIN OUTCOME MEASURES: The primary outcome measure was Patient Health Questionnaire-9 items score at 4 months post randomisation. Secondary outcome measures included depression severity and caseness at 12 and 18 months, the EuroQol-5 Dimensions, Short Form questionnaire-12 items, Patient Health Questionnaire-15 items, Generalised Anxiety Disorder-7 items, Connor-Davidson Resilience Scale-2 items, a medication questionnaire, objective data and adverse events. Participants were followed up at 12 and 18 months. RESULTS: In total, 485 participants were randomised (collaborative care, n = 249; usual care, n = 236), with 390 participants (80%: collaborative care, 75%; usual care, 86%) followed up at 4 months, 358 participants (74%: collaborative care, 70%; usual care, 78%) followed up at 12 months and 344 participants (71%: collaborative care, 67%; usual care, 75%) followed up at 18 months. A total of 415 participants were included in primary analysis (collaborative care, n = 198; usual care, n = 217), which revealed a statistically significant effect in favour of collaborative care at the primary end point at 4 months [8.98 vs. 10.90 score points, mean difference 1.92 score points, 95% confidence interval (CI) 0.85 to 2.99 score points; p < 0.001], equivalent to a standard effect size of 0.34. However, treatment differences were not maintained in the longer term (at 12 months: 0.19 score points, 95% CI -0.92 to 1.29 score points; p = 0.741; at 18 months: < 0.01 score points, 95% CI -1.12 to 1.12 score points; p = 0.997). The study recorded details of all serious adverse events (SAEs), which consisted of 'unscheduled hospitalisation', 'other medically important condition' and 'death'. No SAEs were related to the intervention. Collaborative care showed a small but non-significant increase in quality-adjusted life-years (QALYs) over the 18-month period, with a higher cost. Overall, the mean cost per incremental QALY for collaborative care compared with usual care was £26,016; however, for participants attending six or more sessions, collaborative care appears to represent better value for money (£9876/QALY). LIMITATIONS: Study limitations are identified at different stages: design (blinding unfeasible, potential contamination), process (relatively low overall consent rate, differential attrition/retention rates) and analysis (no baseline health-care resource cost or secondary/social care data). CONCLUSION: Collaborative care was effective for older people with case-level depression across a range of outcomes in the short term though the reduction in depression severity was not maintained over the longer term of 12 or 18 months. Participants who received six or more sessions of collaborative care did benefit substantially more than those who received fewer treatment sessions but this difference was not statistically significant. FUTURE WORK RECOMMENDATIONS: Recommendations for future research include investigating the longer-term effect of the intervention. Depression is a recurrent disorder and it would be useful to assess its impact on relapse and the prevention of future case-level depression. TRIAL REGISTRATION: Current Controlled Trials ISRCTN45842879. FUNDING: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 21, No. 67. See the NIHR Journals Library website for further project information.

Optimizing the Care Coordinator Role in Primary Care: A Qualitative Case Study.

BACKGROUND: Care coordinators (CCs) are increasingly employed in primary care as a means to improve health care quality, but little research examines the process by which CCs are integrated into practices. This case study provides an in-depth examination of this process and efforts to optimize the role. METHODS: Two CCs' work was observed and assessed, and attempts were made to optimize the role using workflow modeling and "Plan-Do-Study-Act" cycles. Rolling qualitative analyses of field notes from key informant interviews and team meetings were conducted using iterative cycles of "immersion/crystallization" to identify emerging themes. RESULTS: Expected roles of CCs included case management of high-risk patients, transitions of care, and population management. Case management was the least difficult to implement; transition management required more effort; and population management met with individual and institutional obstacles and was difficult to address. CONCLUSIONS: The process by which CCs are integrated into primary care is not well understood and will require more attention to optimally use this role to improve health care quality. Understanding aspects of CCs' roles that are the least and most difficult to integrate may provide a starting place for developing best practices for implementation of this emerging role.

CollAborative care and active surveillance for Screen-Positive EldeRs with subthreshold depression (CASPER): a multicentred randomised controlled trial of clinical effectiveness and cost-effectiveness.

BACKGROUND: Efforts to reduce the burden of illness and personal suffering associated with depression in older adults have focused on those with more severe depressive syndromes. Less attention has been paid to those with mild disorders/subthreshold depression, but these patients also suffer significant impairments in their quality of life and level of functioning. There is currently no clear evidence-based guidance regarding treatment for this patient group. OBJECTIVES: To establish the clinical effectiveness and cost-effectiveness of a low-intensity intervention of collaborative care for primary care older adults who screened positive for subthreshold depression. DESIGN: A pragmatic, multicentred, two-arm, parallel, individually randomised controlled trial with a qualitative study embedded within the pilot. Randomisation occurred after informed consent and baseline measures were collected. SETTING: Thirty-two general practitioner (GP) practices in the north of England. PARTICIPANTS: A total of 705 participants aged ≥ 75 years during the pilot phase and ≥ 65 years during the main trial with subthreshold depression. INTERVENTIONS: Participants in the intervention group received a low-intensity intervention of collaborative care, which included behavioural activation delivered by a case manager for an average of six sessions over 7-8 weeks, alongside usual GP care. Control-arm participants received only usual GP care. MAIN OUTCOME MEASURES: The primary outcome measure was a self-reported measure of depression severity, the Patient Health Questionnaire-9 items PHQ-9 score at 4 months post randomisation. Secondary outcome measures included the European Quality of Life-5 Dimensions, Short Form questionnaire-12 items, Patient Health Questionnaire-15 items, Generalised Anxiety Disorder seven-item scale, Connor-Davidson Resilience Scale two-item version, a medication questionnaire and objective data. Participants were followed up for 12 months. RESULTS: In total, 705 participants were randomised (collaborative care n = 344, usual care n = 361), with 586 participants (83%; collaborative care 76%, usual care 90%) followed up at 4 months and 519 participants (74%; collaborative care 68%, usual care 79%) followed up at 12 months. Attrition was markedly greater in the collaborative care arm. Model estimates at the primary end point of 4 months revealed a statistically significant effect in favour of collaborative care compared with usual care [mean difference 1.31 score points, 95% confidence interval (CI) 0.67 to 1.95 score points; p < 0.001]. The difference equates to a standard effect size of 0.30, for which the trial was powered. Treatment differences measured by the PHQ-9 were maintained at 12 months' follow-up (mean difference 1.33 score points, 95% CI 0.55 to 2.10 score points; p = 0.001). Base-case cost-effectiveness analysis found that the incremental cost-effectiveness ratio was £9633 per quality-adjusted life-year (QALY). On average, participants allocated to collaborative care displayed significantly higher QALYs than those allocated to the control group (annual difference in adjusted QALYs of 0.044, 95% bias-corrected CI 0.015 to 0.072; p = 0.003). CONCLUSIONS: Collaborative care has been shown to be clinically effective and cost-effective for older adults with subthreshold depression and to reduce the proportion of people who go on to develop case-level depression at 12 months. This intervention could feasibly be delivered in the NHS at an acceptable cost-benefit ratio. Important future work would include investigating the longer-term effect of collaborative care on the CASPER population, which could be conducted by introducing an extension to follow-up, and investigating the impact of collaborative care on managing multimorbidities in people with subthreshold depression. TRIAL REGISTRATION: Current Controlled Trials ISRCTN02202951. FUNDING: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 21, No. 8. See the NIHR Journals Library website for further project information.