Age and Ageing Advance Access originally published online on March 26, 2007
Age and Ageing 2007 36(3):336-339; doi:10.1093/ageing/afm028
Assessing the impact of care management in the community: associations between key organisational components and service outcomes
SIR—Care management was introduced in the UK in e 1990 National Health Service (NHS) and Community Care Act. Originally envisaged for people whose needs were complex or required significant levels of resource—to coordinate care, review needs and to use resources to good effect [1]—care management for older people has developed in a varied manner across England. A common observation has been the lack of differentiation of care management arrangements: a form of targeting whereby different levels of service response are triggered by different levels of need [2–5]. In particular, the implementation of an intensive care management service is rare [5] despite evidence of the effectiveness of a more targeted approach [4, 6, 7]. A second feature has been the infrequent development of integrated systems of care management for older people [8]. This is despite care management being continually cited as the cornerstone of coordinated care and key to providing integrated care packages for frail older people with complex needs [1, 9].More recently, the concept of care management has been reintroduced into older people's services by government policy aiming to support people with long-term conditions at particular risk of repeated hospital admissions [10]. Nurse-led, and re-badged case management, it nonetheless incorporates elements of targeting and integration common to care management as it was first envisaged.
Research has estimated that over 80 per cent of decisions to place older people into care homes may be explained by the characteristics of the individual and that supply factors, whilst significant, do not add to this [11]. Thus, differences in the care management arrangements developed by individual social services departments may explain at least some of the residual variation in care home admissions and, potentially, other indicators of performance in older people's services. Using the key features of variation in care management arrangements described by Challis et al. [12–14], we aimed to determine which, if any, were associated with the variation in performance.
This study employed multiple linear regression techniques using matched primary and secondary datasets. The primary data were collected as part of a national postal survey of care management arrangements for older people across all English local authorities (n = 131), conducted in 1997/98 and securing a 77 per cent response rate [13, 14]. Ten variables were selected for the current analysis:
- Budget devolved to first tier management or below (81% of survey respondents)
- NHS staff involved in all core tasks of care management (12%)
- Existing NHS care managers for older people (21%)
- Two or more tiers of assessment (85%)
- All review periods specified (55%)
- Usually continuity of care manager from assessment onwards (42%)
- Care management staff based in specialist older people's teams (53%)
- Some evidence of targeting of services in relation to needs (51%)
- Average active caseload size <30 (36%)
- Existing small caseload, high needs service (intensive care management) (6%)
Two controlling variables were added to the regressions: social services net expenditure per head of the population aged over 65 [15] and the supply of residential care beds [16] for each area in 1997 (Appendix 1, supplementary data, http://www.ageing.oupjournals.org/).
The secondary data employed as outcome variables in the regressions were derived from Audit Commission [15] and Department of Health [17, 18] routinely generated performance indicators for 1997/98 (Appendix 1). The first two of these indicators—the proportions of the older population helped to live at home or admitted to residential care—were taken directly from the 1997/98 datasets. The third indicator, the closest approximation to intensive home care available at the time, was derived from the product of the percentage of all adult households receiving six or more visits per week and the number of older households receiving home care. The final indicator represents the balance of care between residential and home care, expressed as a ratio of the first two indicators.
Regressions were performed using SPSS for Windows version 10 on each outcome variable using backwards elimination until the adjusted R2 was maximised. These models initially included the ten components of care management described above, together with the controlling variables. This enabled the determination of the combination of available factors which best explained the variation in performance. Adjusted R2 values are presented with Beta coefficients (95% confidence intervals) and corresponding significance levels.
Table 1 presents the models derived. All four models provided significant explanations of the variance in the performance indicator in question, explaining between 11 and 45 per cent of the variance. In all cases, supply of residential care beds proved not to be a significant factor. Conversely, social services net expenditure, was a highly significant factor in all, bar the final model.
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Discussion
These findings are some of the first, which have linked local data on service delivery and organisation, in this case, care management arrangements, with routinely collected national outcome data. None of the regression equations produced a very strong goodness-of-fit. Thus, the organisational features of care management did not prove to be a very powerful influence upon the outcomes measured. However this is not surprising since what is being estimated is a relationship between practice level approaches and macro level outcomes, which are subject to multiple influences and less likely to be detected in an ecological study such as this. Moreover, as described earlier [11], a large proportion of the variance in nursing and residential home admissions is dependent upon the characteristics of the individual older person. Nonetheless, examination of the significant explanatory variables suggests consistent and expected effects.
Of particular interest, are the suggested effects of integrated forms of care management and those indicative of a differentiated approach, themes resonant throughout care management practice and policy. Although social services expenditure generally had a greater impact on outcomes, the involvement of health professionals in care management processes and as care managers, caseload size and the existence of intensive care management schemes all demonstrated significant associations.
In the first model, the presence of NHS care managers was negatively associated with a more widespread approach to provision of care at home. This might suggest that a more integrated model of care management was employed where services were more targeted, perhaps with a focus upon more vulnerable individuals. Conversely, the involvement of NHS staff in all core tasks of care management was associated with a greater proportion of older people receiving home care services. However, it was also associated with a greater proportion of permanent care home admissions and a balance of care more in favour of institutional care. These findings may have implications for recent developments integrating health and social care services for older people, for example Care Trusts or services utilising the 1999 Health Act flexibilities. While intuitively beneficial for older people with complex needs, the supporting research evidence for integrated services is still lacking.
As expected, the presence of intensive care management, itself not common in services for older people [5, 14], was associated with a higher proportion of older people receiving care packages involving more resource. Furthermore, we have demonstrated a negative association between the existence of an intensive care management scheme for older people and the ratio of older people permanently admitted to a care home to those helped to live at home. These data provide evidence in support of this type of provision as an alternative to entering a care home for frail older people. In models II and IV, the presence of smaller caseloads also proved to be a significant factor. This was associated with a lower proportion of the older population being admitted to care homes and also with a balance of care that was less residentially oriented. As small caseloads were identified as one of the necessary (but not sufficient) components of intensive care management [5], this would again seem to be an entirely expected observation.
While there are some important limitations to this study—namely, the age of the data, the proxy indicator used for intensive home care and the absence of indicators of need (all of which are fully acknowledged and furnished in Appendix 2 in the supplementary data at http://www.ageing.oupjournals.org/)—this analysis suggests that associations may exist between organisational arrangements for care management and service level outcomes. The impact of more integrated forms of care coordination for older people, as espoused by the Department of Health [10, 19, 20] is not clear-cut. However, the findings lend support to the argument based on inspections, policy review and research [2–5, 14] that if care management is to have an impact upon the balance of care in any locality—and thus upon the use of ever-limited resources—then, some degree of differentiation of care management arrangements by need is required, one element of this being approaches akin to intensive care management. This may be particularly important for the development of NHS case management where appropriate targeting of the service may prove to be key to the successful reduction of in-patient episodes [21]. However, given the potential weaknesses of an ecological study and the possibility of ‘ecological fallacy’ [22], further investigations measuring outcomes at the level of the service user in a selection of local authorities operating a variety of service configurations would be necessary to confirm or refute these findings.
- Wide variation exists across England within care management arrangements for older people living at home.
- Intensive care management services are rare and integrated modes of service delivery uncommon.
- This analysis, linking data from a national survey of care management arrangements with routinely generated community care performance indicators, demonstrates weak but significant associations.
- Lends support to the argument that a degree of differentiation within care management arrangements is required if it is to have an impact on the balance of care for older people.
Acknowledgements and declarations
The survey of care management arrangements on which this paper was based was funded by the Department of Health. Any views expressed in this paper are those of the authors alone. The authors would like to thank Robin Darton, Jane Hughes, Paula Mandall, Karen Stewart and Kate Weiner for their contributions to the design, administration and data preparation of the original survey. We are most grateful to the local authorities and their staff for their participation in the research. Conflicts of interest: none.
PSSRU, 1st Floor Dover Street Building, The University of Manchester, Oxford Road, Manchester M13 9PL, UK
* To whom correspondence should be addressed Email: sally.jacobs{at}manchester.ac.uk
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