Effectiveness of a social robot, "Paro," in a VA long-term care setting.

Interest in animal assisted interventions (AAI) has grown over the years, but acceptance of AAI by the clinical and research community has been hampered by safety, hygiene, and logistical concerns. Advances in the field of social robotics have provided a promising route to deliver AAI while avoiding these aforementioned obstacles. Although there has been promising initial research on social robotics in older adults, to date there has been no such research conducted with a veteran population. The present pilot study followed 23 veteran residents of a Veterans Affairs (VA) geropsychiatric long-term care facility over the span of approximately a year and a half. It was found that use of Paro, a social robot, resulted in increased observed positive affective and behavioral indicators, with concomitant decreases observed in negative affective and behavioral indicators. The authors concluded that Paro is likely an effective nonpharmacological approach for managing dementia-related mood and behavior problems with veterans in VA long term care facilities. They additionally observed that Paro is best presented to residents who are relatively calm and approachable, as opposed to actively exhibiting behavior or mood problems. Future research directions are discussed in light of both the positive results noted and the inherent limitations of our pilot study. (PsycINFO Database Record

Speaking up in case management, part II: implementing speaking up behaviors.

OBJECTIVES: Case managers will occasionally witness colleagues from their own or other healthcare disciplines providing care in ways that frankly deviate from or violate standards of care, rules, regulations, policies, and procedures. This article discusses the case manager's ethical obligation to speak up in such instances, as well as lists strategies and techniques that facilitate and enhance professional communications around "speaking up." PRIMARY PRACTICE SETTINGS: All case management work environments. FINDINGS/CONCLUSIONS: When healthcare professionals practice in ways that deviate from established policies, procedures, rules, regulations, and standards of care, they jeopardize the safety and welfare of their clients and, often, their employing institutions. Unfortunately, professionals often remain silent about such errors and deviations for fear that they might suffer retaliation if they speak up or because they do not anticipate a constructive or positive organizational response. Nevertheless, organizations and employees who recognize the value of speaking up can use a variety of strategies described in this article that enable speaking up to become a professional and organizational reality. IMPLICATIONS FOR CASE MANAGEMENT PRACTICE: Because they practice in the midst of multidisciplinary care, case managers have a marked opportunity to witness any number of practice standards being ignored or violated. Case managers need to develop communication skills and organizational savvy regarding how to approach and remedy such situations, especially when deviations from standards of care have become routine or "normalized." Critical elements in speaking up include cultivating a method to discern the moral perils of remaining silent, learning communication techniques to conduct emotionally challenging conversations, and building organizational leadership that recognizes the value of speaking up and supports safe harbors for employees who speak up appropriately.

Speaking up in case management, part I: ethical and professional considerations.

OBJECTIVES: Case managers will occasionally witness colleagues from their own or other healthcare disciplines providing care in ways that frankly deviate from or violate standards of care, rules, regulations, policies, and procedures. This article will discuss the case manager's ethical obligation to speak up in such instances as well as list strategies illustrated in this article by a three-color flag system that classifies poor, better, and best responses to ethically challenging situations. PRIMARY PRACTICE SETTINGS: All case management work environments. FINDINGS/CONCLUSIONS: When health professionals practice in ways that deviate from established policies, procedures, rules, regulations, and standards of care, they jeopardize the safety and welfare of their clients and, often, their employing institutions. Although speaking up is often difficult due to fears of retaliation or an organizational nonresponse, the fundamental ethical obligation of case managers is to protect and further their client's health and welfare rather than their professional self-interests. Consequently, the ethically conscientious case manager will pursue strategies whereby weaknesses or latent hazards that might compromise a client's care can be remediated. IMPLICATIONS FOR CASE MANAGEMENT PRACTICE: Because they practice in the midst of multidisciplinary care, case managers have a marked opportunity to witness any number of practice standards being ignored or violated. Case managers need to cultivate a heightened moral awareness and response to such situations, especially when deviations from standards of care have become routine or "normalized." Critical elements in speaking up include cultivating a method to discern the moral perils of remaining silent, learning communication techniques to conduct emotionally challenging conversations, and building organizational leadership that recognizes the value of speaking up and supports safe harbors for employees who speak up appropriately.

Hitch up your humor suspenders, case managers.

PURPOSE/OBJECTIVES: Although case managers must project professionalism, a dash of healing humor can accomplish a lot of trust in a little space of time. To show how case managers can incorporate humor into case management (CM), the article explores beneficial humor-based interventions and sources of unhealthy humor. Suspending the garment of good humor are 2 main straps: (1) increasing the theoretical knowledge base about healthcare humor for case managers and (2) encouraging knowledge transfer through appropriate humorous exchanges up and down the care continuum bucket brigade. IMPLICATIONS FOR CASE MANAGEMENT PRACTICE: With backgrounds in social work, nursing, therapy, and even doctoring, CM practitioners see the soft underbellies of people's lives. From evidence-based research, case managers can garner tips for humor tact and identify ways to incorporate them into CM practice. Recommendations are elaborated to achieve positive outcomes of authentic communication and improving the quality of healthcare experiences. Examples include recognizing boundaries of unfunny and funny, dignifying and humanizing interactions through levity, responding to age groups appropriately, and drawing from client-preference tidbits like inspirational songs and humorous stories. Avoiding negative outcomes is discussed, especially harming with humor. Five common displays of the humor coin's flip side and ethical erosion are presented. FINDINGS/CONCLUSIONS: To aid case managers, caregivers, and clients in fortifying their coping mechanisms, research findings showcase not only the good but also the bad and the ugly such as interventions to avoid. Findings spotlight appropriate uses of humorous antics, bells and whistles signaling low humor and high risk, and simple takeaways case managers can tuck in their satchels. The article's multipronged conclusion is that respectful humor used judiciously can buoy clients' spirits, bring spoonfuls of levity to a sea of seriousness, show humility that softens the stiff authoritarian semblance of control, and increase clients' confidence that their proverbial exposed underbellies are in safe hands. Pile in the little red research vehicle with the author on this purposeful journey of jocularity. As the slogan goes, many true things are said in jest. Hitch up Your Humor Suspenders is one of them.

Quality in translation: case management in the international marketplace.

PURPOSE: This article identifies three categories of case management (CM), in-country, international, and micro, that are poised to serve as the quality proxy for the international medical patient in the rapidly emerging globalized healthcare marketplace. The content concentrates on describing in-country CM and international CM (ICM). Because CM professionals are the providers of patient-centered quality and safety improvements, they are capable of filling the chasm between the travel industry and the regulators who specialize in accrediting hospital systems. In-country and ICM case managers are equipped to perform surveillance and intervention at the level of the international patient's bedside, activate network connections, and use culture-sensitive communication skills to safeguard patients in their individual sojourns abroad. The article discusses useful concepts and sources, including an algorithmic tool under development that is geared to identify and quantify risks for lay and business individuals who seek to engage the global medical market. PRIMARY PRACTICE SETTING(S): The article's information is provided for front-line and front-office healthcare practitioners to understand or enter the worldwide medical marketplace. Content is targeted to CM generalists, specialists, and business developers interested in learning about safeguarding the patients who travel internationally to receive medical care. It can also be applied by those within and outside the healthcare practice arena, particularly those interested in the development of quality initiatives. METHODS: All research and syntheses were executed by the authors. Sources included scholarly treatises, business correspondence, medical tourism literature, corporate Internet profiles, news releases, and healthcare industry investigative and monitoring agencies. International health insurance, economics, and financing expertise stems from one author (L.B.). Clinical competencies stem from the international practice experiences of one author (K.C.). RESULTS: This article identifies Web sites and sources that constitute high-quality resources for ongoing reference by ICM practitioners. Two strategic tools are introduced: one for assessing the readiness of the regional marketplace for CM and the Beichl-Craig Medical Travel Risk Evaluator for international medical consumer risk identification. IMPLICATIONS FOR CM PRACTICE: The emerging global healthcare marketplace is certain to change the way case managers anticipate and respond to care delivery concerns in different regional systems. A systematic structure for analyzing specific country and CM "readiness" is introduced. For case managers who assist clients to receive care internationally, the application of these concepts will help them know where a range of potential obstacles lie and how to calibrate risks and set realistic expectations. For healthcare product developers and quality analysts, the information will help stimulate discourse regarding innovative strategies, tools, and metrics geared to identify, measure, and mitigate risks for patients in the global medical marketplace.

Globalization of healthcare: case management in a 21st-century world.

PURPOSE: This article explains the current state of the global healthcare market with respect to international medical travel (medical tourism) and worldwide provider sourcing. Emphasis is placed on the traditional twin pillars of oversight: program accreditation and branding affiliation. These are discussed for their main strength, which is their ability to operate at a system-strata level. This strength also represents a primary weakness from the international patient's perspective, which is the functional gap between systemic oversight and bedside surveillance. International case management (ICM) is identified as the right conduit of patient-level service delivery that fills the gap between system and bedside. The ICM professional is introduced and defined as the provider of patient-centered quality and safety improvements, who coordinates and collaborates using international network connections and culture-sensitive in-country communication skills. PRIMARY PRACTICE SETTING(S): The article's information is useful for healthcare practitioners who want to learn about the global medical marketplace. Practitioners who are preparing to or who already have business enterprises associated with the global healthcare market will also find the information helpful. Explanations and content are useful to case management generalists, specialists, and business developers. The content is intended for uptake by interested parties within and outside the healthcare practice arena. METHODOLOGY: All research and syntheses were executed by the authors. Sources included business correspondences, medical tourism literature, corporate Internet profiles, news releases, and healthcare industry investigative and monitoring agencies. Clinical competencies stem from the international practice experiences of one author (K. Craig). International health insurance, economics, and financing expertise stems from other author (L. Beichl). RESULTS: This article launches the platform for development of checklists, tools, and guidelines for international case management practice. IMPLICATIONS FOR CASE MANAGEMENT PRACTICE: The article focuses on (1) the examination of traditional quality safeguards of accreditation and branding and (2) the introduction of patient-centered ICM practices. The article aims to identify sources of risk for individual medical consumers who travel across national borders to seek medical care and methods of risk mitigation, especially international case management.

Implementing an automated acuity tool for scoring case management cases and caseloads at Blue Cross Blue Shield of Massachusetts.

PURPOSE/OBJECTIVES: Blue Cross Blue Shield of Massachusetts (BCBSMA) required a statistically validated tool to understand the acuity of its case management (CM) populations. The BCBSMA management sought reliable methods to quantify the weights of case managers' caseloads, allow associates and managers to have conversations about workloads based on objective measurable data, and analyze the data to ensure that the correct populations are being targeted for CM. PRIMARY PRACTICE SETTING(S): The tools, techniques, and strategies described in the Acuity and eQuity Workflow Solutions are suitable for all healthcare practice settings. Acuity scoring metrics are designed especially for CM settings such as independent stand-alone companies, inpatient and outpatient practices, and multistrata health plans and hospital consortia. FINDINGS/CONCLUSIONS: The customized BluCuity assessment tool, tested in the interrater reliability (IRR) study arm of the project, was validated to a high degree of concordance in BluCuity scoring among CM raters with an overall agreement of 82% (20 novel raters, 20 cases, 190 rater pairs, 3,800 pairwise case reviews; p = .03). The BluCuity tool and workflow strategies were implemented into the BCBSMA information technology (IT) system for oncology and other CM teams in 2008. Report data demonstrated the acuities of case managers' cases, the relative case and caseload weights among a team of case managers, and the differences in cases and caseloads across CM product offerings. IMPLICATIONS FOR CASE MANAGEMENT PRACTICE: Acuity-based tools such as BluCuity to access the severity, intensity, and complexity of CM cases operationalize quality assessments into quantifiable data. Acuity score reports can join other accounting and operational reports to determine appropriate caseloads, case assignments, and staffing. To assess consistency of judgment among case managers, CM organizations can implement a formal IRR testing methodology to evaluate the level of clinical assessment reliability and establish training protocols. The automated IT acuity assessment system and data outputs can be used to assess the overall weight of a caseload based on diagnosis code groupings such as oncology, pediatric, transplants, and stroke, and illustrate the intensity of services required by CM clients at different times or in different programs. Organizations that sell CM services can use the ability to score the acuity of CM cases to scale and justify the pricing of their services.

Acuity and case management: a healthy dose of outcomes, part II.

PURPOSE: This is the second of a 3-part series presenting 2 effective applications-acuity and dosage-that describe how the business case for case management (CM) can be made. In Part I, dosage and acuity concepts were explained as client need-severity, CM intervention-intensity, and CM activity-dose prescribed by amount, frequency, duration, and breadth of activities. Part I also featured a specific exemplar, the CM Acuity Tool, and described how to use acuity to identify and score the complexity of a CM case. Appropriate dosage prescription of CM activity was discussed. Part II further explains dosage and presents two acuity instruments, the Acuity Tool and AccuDiff. Details are provided that show how these applications produce opportunities for better communication about CM cases and for more accurate measurement of the right content that genuinely reflects the essentials of CM practice. PRIMARY PRACTICE SETTING(S): The information contained in the 3-part series applies to all CM practice settings and contains ideas and recommendations useful to CM generalists, specialists, and supervisors, plus business and outcomes managers. The Acuity Tools Project was developed from frontline CM practice in one large, national telephonic CM company. METHODOLOGY AND SAMPLE: Dosage: A literature search failed to find research into dosage of a behavioral intervention. The Huber-Hall model was developed and tested in a longitudinal study of CM models in substance abuse treatment and reported in the literature. Acuity: A structured literature search and needs assessment launched the development of the suite of acuity tools. A gap analysis identified that an instrument to assign and measure case acuity specific to CM activities was needed. Clinical experts, quality specialists, and business analysts (n = 7) monitored the development and testing of the tools, acuity concepts, scores, differentials, and their operating principles and evaluated the validity of the Acuity Tools' content related to CM activities. During the pilot phase of development, interrater reliability testing of draft and final tools for evaluator concordance, beta (beta) testing for content accuracy and appropriateness, and representative sample size testing were done. Expert panel reviews occurred at multiple junctures along the development pathway, including the 5 critical points after initial tool draft and both before and after beta-test (n = 5) and pilot-test (n = 28) evaluations. The pilot testing body (n = 33) consisted of a team of case managers (n = 28) along with quality analysts (n = 2), supervisory personnel (n = 2), and the lead product analyst (the developer). Product evaluation included monitoring weekly reports of open cases for the 28 case managers for 3 months (June-August 2000). RESULTS: The Acuity Tools suite was used to calculate individual case acuity, overall caseload acuity profiles, case length, and acuity differentials. Normal distributions and outliers were analyzed and the results used for internal quality improvement and outcomes monitoring. IMPLICATIONS FOR CASE MANAGEMENT PRACTICE: To show value, case managers need to access the evidence base for practice, use tools to capture quantities of intervention intensity, and specify precisely the activities that produce better outcomes. Acuity and dosage can help case managers explore and fully describe their own practice in ways that can be measured. This data-driven evidence contributes to the accumulating body of definitive proof regarding the exceptional worth of CM. Proving business and professional worth in CM though evidence-based practice is a clarion call that case managers must heed and an innovation that all case managers can practice.

Acuity and case management: a healthy dose of outcomes, part I.

PURPOSE OF STUDY: This article presents acuity and dosage as two concepts that describe how the business case for case management (CM) can be made. Dosage and acuity concepts are explained as client need-severity, CM intervention-intensity, and CM activity-dose by amount, duration, extent, and timing. Concepts are related to the practice of CM using evidence-based knowledge and methods to develop instruments that measure and score pivotal CM actions. The purpose of this series of three articles is to introduce the two concepts of dosage and acuity, discuss their importance for making the business case for CM and for translation into evidence-based practice, and present a powerful example of how they can be used in everyday CM. The articles feature a specific exemplar, the CM Acuity Tools project, and explain how the melding of the acuity and dosage innovations will improve the capture of CM outcomes. Part I focuses on the CM Acuity Tool(c) instrument. PRIMARY PRACTICE SETTING(S): The article's information applies to all CM practice settings, and contains ideas and recommendations useful to CM generalists, specialists, supervisors, and outcomes managers. The Acuity Tools Project was developed from frontline CM practice in one large, national telephonic CM company. METHODOLOGY AND SAMPLE: For dosage, the Huber-Hall Dosage Model and its testing are described and explained. The intersection of dosage and acuity is analyzed. For the Acuity Tools Project, a structured literature search and needs assessment launched the development of the suite of acuity tools. The resulting gap analysis identified that an instrument to assign and measure case acuity specific to CM activities was needed. Clinical experts, quality specialists, and business analysts (n = 7) monitored the development and testing of the tools, acuity concepts, scores, differentials, and their operating principles, and evaluated the validity of the acuity tools' content related to CM activities. During the pilot phase of development, interrater reliability testing of draft and final tools for evaluator concordance, beta (beta) testing for content accuracy and appropriateness, and representative sample size testing were done. Expert panel reviews occurred at several junctures along the development pathway, including after initial tool draft and both before and after beta-tests (n = 5) and pilot tests (n = 28). The pilot testing body (n = 33) consisted of a team of case managers (n = 28) along with quality analysts (n = 2), supervisory personnel (n = 2), and the lead product analyst (the developer). Product evaluation included monitoring weekly reports of open cases for the 28 case managers for 3 months (June to August 2000). RESULTS: Positive results generated approval from the expert review panel to apply the suite of acuity tools beyond (1) the initial draft phase, (2) the test population phase, and then (3) at a national CM organization level. IMPLICATIONS FOR CASE MANAGEMENT PRACTICE: This article defines and discusses acuity and dosage as two practical conceptual tools that successfully unite clinical quality and business practices and measure and analyze CM activities. The CM Acuity Tool(c) is a master conceptual framework in three dimensions that synthesizes key components of CM practice, organized into indicators, drivers, and subdrivers. To show value, case managers need to access the evidence base for practice, use tools to capture quantities of intervention-intensity, and specify the activities that produce better outcomes.

Acuity and case management: a healthy dose of outcomes, part III.

PURPOSE OF STUDY: This is the third of a 3-part series presenting 2 effective applications--acuity and dosage--that describe how the business case for case management (CM) can be made. In Part I, dosage and acuity concepts were explained as client need-severity, CM intervention-intensity, and CM activity-dose prescribed by amount, frequency, duration, and breadth of activities. Concepts were presented that related the practice of CM to the use of evidence-based practice (EBP), knowledge, and methods and the development of instruments that measure and score pivotal CM actions. Part I also featured a specific exemplar, the CM Acuity Tool, and described how to use acuity to identify and score the complexity of a CM case. Part II further explained dosage and 2 acuity instruments, the Acuity Tool and AccuDiff. Part III presents linkage to EBP and practical applications. PRIMARY PRACTICE SETTING(S): The information contained in the 3-part series applies to all CM practice settings and contains ideas and recommendations useful to CM generalists, specialists, supervisors, and business and outcomes managers. The Acuity Tools Project was developed from frontline CM practice in one large, national telephonic CM company. METHODOLOGY AND SAMPLE: Dosage: A literature search failed to find research into dosage of a behavioral intervention. The Huber-Hall model was developed and tested in a longitudinal study of CM models in substance abuse treatment and reported in the literature. Acuity: A structured literature search and needs assessment launched the development of the suite of acuity tools. A gap analysis identified that an instrument to assign and measure case acuity specific to CM activities was needed. Clinical experts, quality specialists, and business analysts (n = 7) monitored the development and testing of the tools, acuity concepts, scores, differentials, and their operating principles and evaluated the validity of the acuity tools' content related to CM activities. During the pilot phase of development, interrater reliability testing of draft and final tools for evaluator concordance, b testing for content accuracy and appropriateness, and representative sample size testing were done. Expert panel reviews occurred at multiple junctures along the development pathway, including the 5 critical points after initial tool draft and both before and after b-test (n = 5) and pilot-test (n = 28) evaluations. The pilot testing body (n = 33) consisted of a team of case managers (n = 28) along with quality analysts (n = 2), supervisory personnel (n = 2), and the lead product analyst (the developer). Product evaluation included monitoring weekly reports of open cases for the 28 case managers for 3 months (June-August 2000). RESULTS: The Acuity Tools Suite was used to calculate individual case acuity, overall caseload acuity profiles, case length, and acuity differentials. Normal distributions and outliers were analyzed and the results were used for internal quality improvement and outcomes monitoring. IMPLICATIONS FOR CM PRACTICE: To show value, case managers need to access the evidence base for practice, use tools to capture quantities of intervention intensity, and precisely specify the activities that produce better outcomes. Acuity and dosage can help case managers explore and fully describe their own practice in ways that can be measured, and thus provide data and evidence that contributes to the accumulating body of definitive proof regarding the exceptional worth of CM. Proving business and professional worth in CM through EBP is a clarion call that case managers must heed and an innovation that all case managers can practice.