Academic journal article Care Management Journals

Development of an Individualized Service Plan Tool and Rules for Case Management in Québec

Academic journal article Care Management Journals

Development of an Individualized Service Plan Tool and Rules for Case Management in Québec

Article excerpt

From past experience with integrated service delivery, there appears to be a need for a clinical tool to help case managers plan, monitor, and coordinate services. In this context the Québec Ministry of Health and Social Services created a task force to suggest improvements to the Individualized Service Plan tool included in the Multiclientele Assessment Tool. This article reports the findings of this multidisciplinary task force working with various clienteles (older, with physical or mental disabilities, mental diseases). Based on a literature review and recent results from the Program of Research on the Integration of Services for the Maintenance of Autonomy, the task force proposed a dynamic, concise, user-friendly tool and a clear definition of how it should be used. The Individualized Service Plan must list the patient's needs, with an orientation regarding the action plan for each, and a list of services allocated in response to these needs that work in the defined direction. The tool must also contain a section for analyzing variations between the services needed and allocated. This tool was presented to case managers for validation and received an enthusiastic response. It should be implemented in the coming years in the provincial Multiclientele Assessment Tool.

Keywords: clinical tool; interdisciplinary recommendations; integrated care; clinical planning process

According to most authors, case management is a process that includes the following tasks (Applebaum & Wilson, 1988; Bernabei et al., 1998; Capitman & Sciegaj, 1995; Challis, Darton, Johnson, Stone, & Traske, 1991; Hebert, Durand, Dubuc, & Tourigny, 2003; Moxley, 1989; Newcomer, Harrington, & Kane, 2002; Pacala et al., 1995; Riley, Fortinsky, & Coburn, 1992; Somme, Hébert, Bravo, & Blanchard, 2004; Tourigny, Durand, Bonin, Hébert, & Rochette, 2004): (a) case identification using predefined criteria; (b) standardized multidimensional assessment; and (c) individualized planning of services and identification of resources, plan implementation, monitoring and reevaluation. The concept of advocacy encompassing advice and representation transcends these different tasks (Capitman & Sciegaj, 1995; Challis et al., 1991; Genrich & Neatherlin, 2001).

Implementing these practices requires everyone involved to adopt a common language, especially through the use of common and validated clinical tools. Case identification depends on strict adherence to case management eligibility criteria, which means that the tools vary greatly across different international experiments. The assessment task resulted in the development of numerous tools such as the Multiclientele Assessment Tool including the Functional Autonomy Measurement System in Québec and the Resident Assessment Instrument in the United States and then in Europe, each with a scientific validation process (Hebert, Carrier, & Bilodeau, 1988; Landi et al., 2000). However, the planning task, which seems relatively constant across different managed care or integrated care experiments (Applebaum & Austin, 1990; Beland et al., 2006; Bernabei et al., 1998; Chamberlain & Rapp, 1991; Foote & Stanners, 2002; Geron & Chassler, 1995; Harrington, Lynch, & Newcomer, 1993; Newcomer, Arnsberger, & Zhang, 1997; Newcomer et al., 2002), does not seem to have received the same attention.

It is widely recognized that every case management user should have a service plan based on the assessment that reflects the client's values and preferences, with a list of objectives to address problems. However, difficulties with implementing individualized service plans have been reported everywhere this has been studied (Applebaum & Austin, 1990; Harrington et al., 1993; Pacala et al., 1995) although the reasons for these difficulties have not been clearly established. Applebaum identified the development of a care plan as a complementary training priority for case managers involved in the Channeling project (Applebaum & Wilson, 1988). …

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