A Realist Evaluation of Case Management Models for People with Complex Health Conditions Using Novel Methods and Tools-What Works, for Whom, and under What Circumstances?

Case management developed from a generalist model to a person-centred model aligned with the evidence-informed evolution of best practice people-centred integrated care. Case management is a multidimensional and collaborative integrated care strategy where the case manager performs a set of interventions/actions to support the person with a complex health condition to progress in their recovery pathway and participate in life roles. It is currently unknown what case management model works in real life for whom and under what circumstances. The purpose of this study was to answer these questions. The study methods used realistic evaluation framework, examined the patterns and associations between case manager actions (mechanisms), the person's characteristics and environment (context), and recovery (outcomes) over 10 years post severe injury. There was mixed methods secondary analysis of data extracted via in-depth retrospective file reviews (n = 107). We used international frameworks and a novel approach with multi-layered analysis including machine learning and expert guidance for pattern identification. The study results confirm that when provided, a person-centred case management model contributes to and enhances the person's recovery and progress towards participation in life roles and maintaining well-being after severe injury.Furthermore, the intensity of case management for people with traumatic brain injury, and the person-centred actions of advising, emotional and motivational support, and proactive coordination contribute to the person achieving their goals. The results provide learnings for case management services on the case management models, for quality appraisal, service planning, and informs further research on case management.

The experience and role of mentorship for paediatric occupational therapists.

INTRODUCTION: Within Australia, the introduction of the National Disability Insurance Scheme has led to a growth in paediatric occupational therapists working in community settings. This growth has increased the demand for support from more senior paediatric occupational therapists to novice clinicians. Mentoring has long been valued by occupational therapists as a means to provide this support. Despite its apparent benefit, there is limited research on the contribution of mentoring as distinct from supervision, and its impact on mentees' skills and confidence in providing care. This study examined the contribution of mentorship to the development of professional capability in paediatric occupational therapy practice from the perspective of mentors and mentees. METHODS: Interpretive description methodology was used. In-depth interviews were conducted with nine mentors and eight mentees from three Australian states. Data were analysed inductively and thematically. FINDINGS: All participants reflected on the challenges presented by the complexity of practice, requiring a knowledge base that mentees perceived they did not possess. The essential nature of non-judgemental, emotional support allowed mentees to feel safe to discuss their concerns when they were often overwhelmed by practice. Mentorship was viewed as capacity building, building competence by scaffolding clinical reasoning and supporting theory to practice translation while developing resilience to cope with complexity. CONCLUSION: Study participants reported that successful mentorship assisted novice practitioners to integrate knowledge and skills required for complex clinical and professional reasoning. The emotional support provided through the relationship supported novice therapists to build their confidence and resilience while promoting professional identity and socialisation into the profession. The study raised questions related to how the profession best supports novice paediatric therapists in the current employment contexts, and the need to review how bodies of knowledge relevant to paediatrics are brought together to be used by both novice clinicians and senior therapists, who support them, for translation to effective practice.

Estimating domestic assistance requirements in medico-legal practice: Australian occupational therapy perspective.

AIM: Occupational therapists are experts in determining domestic assistance levels. It is a complex multi-dimensional process resulting in different opinion regarding care hours. METHOD: Therapists providing medicolegal reports on domestic care for the courts within Australia were surveyed. RESULTS: 58 occupational therapists responded with most aged between 41 to 50 years of age. There was a strong correlation between years of clinical and medicolegal experience (r = 0.730, n = 58, p = 0.000) as well as between years and numbers of medicolegal assessments conducted in 2017 (r = 0.264, n = 58, p = 0.420). Assessment based on occupational analysis interview combined observation of the claimant performing tasks in their home, medical information, and contextual factors such as family expectations. Translation of data to hours of care was based on therapist's clinical experience of medical diagnosis (x2 6.89, p = 0.009) and claimant's statements of performance combined with therapist's clinical experience (x2 = 5.58, p = 0.18). Therapists providing defendant only reports often use their own time to perform housework as a guide. Triangulation data combined confirmation of the person's statements through observation of performance, the environment in which they lived, and the occupational therapists own clinical reasoning skill. CONCLUSION: Documenting all the factors influencing the occupational therapist's decision is the key to understanding clinical reasoning.Implication for rehabilitationWhen estimating domestic care occupational therapists should:•Provide written documentation that clearly explains the assessment methods used, the results and conclusion made regarding domestic care.•Triangulate data including claimant's statements of performance, confirmation by observation on tasks, medical report information in the context of the claimant's environmental and contextual factors.•Be aware their own years of experience do not equate to level of expertise.

A limb to stand on? A scoping review of employability assessment in Australian total and permanent disability insurance claims.

Purpose: Employability assessment helps in deciding to pay or decline Australian total and permanent disability insurance claims, yet it has not been critically examined. This paper reviews employability assessment from forensic vocational assessment, life insurance/superannuation, and legal perspectives.Methods: In a scoping review, we searched six multidisciplinary databases and various industry-specific resources. Items pertinent to forensic employability/vocational assessment and life insurance total and permanent disability claims were included. Return-to-work assessment, the vocational assessor, medical or functional evaluation, and case law items were excluded. Quality appraisal measures were used for research studies and other items. From 104 full-text reviews, 39 items were included for thematic synthesis from the three perspectives of interest.Results: Our review found that employability assessment is derived from forensic vocational assessment, but methodology differs in claimant contact and psychosocial aspects. Employability assessment practice is informed by policy, market changes, and legal interpretation. Assessors may work for opposing sides in forensic or indirect settings therefore high standards and credentials must prevail.Conclusions: Foundational research into the effectiveness of employability assessment and the experience of claimants is warranted. Future research into methodology, assessor credentials, and legal aspects will broaden understanding of this relatively new topic.Implications for rehabilitationEmployability assessment is an emergent and hitherto unexamined model that operates in the multi-billion-dollar Australian total and permanent disability insurance market.Total and permanent disability insurance policies and their legal interpretation are ever-changing and substantially inform employability assessment practice.Employability assessment lacks methodology and variables that are common elements in proven forensic vocational assessment models in the United States.Training and credentialing of rehabilitation professionals who conduct employability assessments are required to withstand legal scrutiny and meet international forensic standards.

Occupational Therapy Domestic Needs Assessment: Lawyer Perspectives.

Occupational therapists are experts in understanding the impact an injury has on a claimant's capacity to perform their pre-injury level of domestic activities. Lawyers use this information when litigating claims for domestic assistance support. This is the first study exploring lawyers' experiences with occupational therapy domestic assistance reports using an online survey. The online survey was completed by 20 lawyers who practise in New South Wales, Australia. Results indicated occupational therapy reports were used to determine the amount of gratuitous domestic care the claimant received, the impact injury has on daily function and tasks requiring assistance. Lawyers used therapists with medico-legal experience although the timeframe for receiving the report was also influential. A high-quality report uses supportive evidence linking function and recommendations for care. Therapists require a clear understanding of the legislation and transparent reasoning while lawyers need to provide sufficient information to assist therapists' conclusions.

Issues facing employability assessment in total and permanent disability insurance claims: A rehabilitation perspective.

BACKGROUND: Expert employment information helps life insurers to decide total and permanent disability claims. The employability assessment model was developed a decade ago by rehabilitation counselors and has not been critically examined. OBJECTIVE: This exploratory descriptive study aims to elicit key issues of employability assessment within Australian life insurance. METHODS: Ten rehabilitation advisors with knowledge of employability assessment in the total and permanent disability sector participated in a single focus group. They each nominated issues of concern about employability assessment. These issues were collated then discussed within the group. Qualitative thematic analysis was used to identify key issues. RESULTS: The predominant theme was the forensic nature of employment evidence. There were three categories of key issues. First, assessment providers- their training, qualifications, experience, and role. Second, methodology- approaches that provide most realistic information about a claimant's likelihood of work. Third, policy definitions that illustrate reliance on legal interpretation of employability. CONCLUSIONS: To withstand legal scrutiny, the credentials of providers, assessment methodology, and quality of forensic reports are key issues which need to be addressed. This foundational study will contribute to broader research on this topic, with implications particularly for rehabilitation, life insurance, and claimants.

Occupational therapy medicolegal assessment of domestic assistance requirements: Focus group perspectives.

BACKGROUND/AIM: Estimating domestic assistance requirements within the medicolegal field is a role for occupational therapists. It is a complex multidimensional process of clinical reasoning with no published research outlining how an occupational therapist translates assessment data into the number of hours of domestic assistance required. This study describes the current occupational therapy practice of estimating domestic assistance hours within the medicolegal context. METHOD: Three focus groups, totalling 14 occupational therapists providing medicolegal reports in New South Wales, were conducted. Sydney University provided ethics approval. Focus group data were thematically analysed. RESULTS: Four themes were identified: Tasks included as housework. Assessment process - interview of pre-injury and recovery status; functional performance on specific tasks and a tour of the home. Influential factors - include legal system restrictions, medical management, cultural and society values, family expectations, location and impact of diagnosis. Strategies to determine care - triangulation of observed data with medical reports and clinical experience. Knowledge of community and own performance times within the framework of occupational therapy philosophy DISCUSSION: No single method of translating assessment data to hours of care was identified. Therapists use of their own housework performance raises ethical issues. Use of claimant only statements raises issues of inaccurate data on which to base decisions. Therapists should refer to occupational therapy process of clinical reasoning to explain their recommendations even though the reasoning does not give a definite number of care hours. CONCLUSION: Therapists need to understand the factors influencing their clinical reasoning when integrating all available information into an estimating of domestic assistance hours. Further study analysing the content of medicolegal report may provide information as to how therapists document their clinical reasoning for court.

Using an adapted Delphi process to develop a survey evaluating employability assessment in total and permanent disability insurance claims.

BACKGROUND: No research has been undertaken about employability assessment of total and permanent disability (TPD) insurance claims. Employability assessment provides vocational information to life insurers to help decide claims. To determine how helpful employability assessment is, a new measure was needed to survey insurers. OBJECTIVE: To generate survey items by harnessing the knowledge and agreement of rehabilitation advisors with expertise in employability assessment. METHODS: A panel of 10 (89% of eligible Australian rehabilitation advisors) participated in an adapted three-round Delphi process. Rounds 2 and 3 were incorporated into a novel real-time card sort format. RESULTS: From 94 potential items submitted for first round qualitative analysis, 36 items in four domains-quality, content, utility, and claims-were generated. Two quantitative ranking rounds in one face-to-face session produced a 21-item prototype. The final electronic survey instrument contained 11 sections seeking insurer demographics and feedback on: external providers; employability assessment concepts, components, quality, and usefulness; functional, occupational, labor market items; and finally, cost and type. Our Delphi process was anonymous, completed in four weeks with 100% response rate and 75% agreement. More time between Rounds 2 and 3 would enhance statistical analysis. CONCLUSIONS: Our adapted Delphi methodology for survey item generation is generalizable for any panel able to meet in person.

The brain injury case management taxonomy (BICM-T); a classification of community-based case management interventions for a common language.

BACKGROUND: Case management is a complex intervention. Complexity arises from the interaction of different components: the model (theoretical basis), implementation context (service), population and health condition, focus for the intervention (client and/or their family), case manager's actions (interventions) and the target of case management (integrated care and support, client's community participation). There is a lack of understanding and a common language. To our knowledge there is no classification (taxonomy) for community-based case management. OBJECTIVE: To develop a community-based case management in brain injury taxonomy (BICM-T), as a common language and understanding of case management for use in quality analysis, policy, planning and practice. METHODS: The mixed qualitative methods used multiple sources of knowledge including scoping, framing and a nominal group technique to iteratively develop the Beta version (draft) of the taxonomy. A two part developmental evaluation involving case studies and mapping to international frameworks assessed the applicability and acceptability (feasibility) before finalization of the BICM-T. RESULTS: The BICM-T includes a definition of community-based case management, taxonomy trees, tables and a glossary. The interventions domain tree has 9 main actions (parent category): engagement, holistic assessment, planning, education, training and skills development, emotional and motivational support, advising, coordination, monitoring; 17 linked actions (children category); 8 related actions; 63 relevant terms defined in the glossary. CONCLUSIONS: The BICM-T provides a knowledge map with the definitions and relationships between the core actions (interventions domain). Use of the taxonomy as a common language will benefit practice, quality analysis, evaluation, policy, planning and resource allocation.

What Is Case Management? A Scoping and Mapping Review.

The description of case management in research and clinical practice is highly variable which impedes quality analysis, policy and planning. Case management makes a unique contribution towards the integration of health care, social services and other sector services and supports for people with complex health conditions. There are multiple components and variations of case management depending on the context and client population. This paper aims to scope and map case management in the literature to identify how case management is described in the literature for key complex health conditions (e.g., brain injury, diabetes, mental health, spinal cord injury). Following literature searches in multiple databases, grey literature and exclusion by health condition, community-based and adequate description, there were 661 potential papers for data extraction. Data from 79 papers (1988-2013) were analysed to the point of saturation (no new information) and mapped to the model, components and activities. The results included 22 definitions, five models, with 69 activities or tasks of case managers mapped to 17 key components (interventions). The results confirm the significant terminological variance in case management which produces role confusion, ambiguity and hinders comparability across different health conditions and contexts. There is an urgent need for an internationally agreed taxonomy for the coordination, navigation and management of care.

High-precision FLIM-FRET in fixed and living cells reveals heterogeneity in a simple CFP-YFP fusion protein.

We have used widefield photon-counting FLIM to study FRET in fixed and living cells using control FRET pairs. We have studied fixed mammalian cells expressing either cyan fluorescent protein (CFP) or a fusion of CFP and yellow fluorescent protein (YFP), and living fungal cells expressing either Cerulean or a Cerulean-Venus fusion protein. We have found the fluorescence behaviour to be essentially identical in the mammalian and fungal cells. Importantly, the high-precision FLIM data is able to reproducibly resolve multiple fluorescence decays, thereby revealing new information about the fraction of the protein population that undergoes FRET and reducing error in the measurement of donor-acceptor distances. Our results for this simple control system indicate that the in vivo FLIM-FRET studies of more complex protein-protein interactions would benefit greatly from such quantitative measurements.

Vocational aspects of life care planning for people with spinal cord injury.

Spinal cord injury (SCI) is a catastrophic event with profound, long-term consequences in all aspects of an individual's life, including employment. The life care plan (LCP) is a methodology that is used to document the continuum of care needs that an individual with SCI will have across his or her life span. The LCP also highlights the critical stages of development necessary to maximize the person's functional potential and productivity. This article provides a brief overview, with a case study example, of how the LCP can be used in addressing an individual's post-injury employability needs.

Transitions related to infection with human immunodeficiency virus (HIV).

Discovery of one's human immunodeficiency virus (HIV) infection, or receiving a diagnosis of acquired immune deficiency syndrome (AIDS), sets in motion a variety of transitions for individuals. Transitions may be characterized by changes in identity or role, changes in physical capacity and functioning, changes in outlook, changes in relationships, changes in routine, etc. Workplaces also face transitions to deal with increasing numbers of workers who are infected with HIV. A model for vocational rehabilitation counselors to assist individuals living with HIV infection in adjusting to their transitions is presented, and resources for providing informational support of individuals and organizations are described.