Professional Case Management最新文献

Purpose of study: Care coordination occurring across multiple sectors of care, such as when professionals in health or social service organizations collaborate to transition patients from hospitals to community-based settings like homeless shelters, happens regularly in practice. While health services research is full of studies on the experiences of case management and care coordination professionals within health care settings, few studies highlight the perspective of nonclinical homeless service providers (HSPs) in coordinating care transitions.

Primary practice setting: This study explores the experience of nonclinical HSPs, employed in a large homeless service agency in New York, United States, responsible for coordinating care transitions of patients presenting to a homeless shelter after hospitalization, with attention to COVID-19 impact.

Methodology and sample: Semi-structured interviews were conducted with providers at three hierarchical levels (frontline, managerial, and executive). The data were analyzed using qualitative content analysis. The implementation science framework Normalization Process Theory was used to structure semi-deductive coding categories.

Results: The findings included three major themes that highlight promoting and inhibiting factors in care coordination, including a reliance on informal relationships, the impact of strong hierarchical structures, and a lack of collaborative cross-sector information exchange pathways. Altogether, findings offer insights from an infrequently studied professional group engaging in cross-sector care coordination for a high-risk population. Operational insights can inform future research to ensure that the implementation of interventions to improve cross-sector care coordination is evidence-based.

Implications for case management practice: This study of nonclinical HSPs facilitating care transitions demonstrates the importance of understanding this critical provider population. Opportunities for acute care case managers and administrators include the importance of relationships, reciprocal education on the differences in work settings, and the need for administrative structure to ensure complex clinical information is effectively translated.

Purpose/objective: Coordinated Behavioral Care began using its Pathway Home program to serve a subset of New York State Adult Home Settlement class members. Through its multidisciplinary team approach, Pathway Home is utilizing its multiphase model in assisting individuals with Serious Mental Illness leaving an Adult Home to successfully transition and remain in the community.

Primary practice setting: The Pathway Home program is a community-based service and serves class members wherever is needed to assist in their recovery and transition from an Adult Home. This includes meeting class members in Adult Homes and various settings in the community.

Findings/conclusions: The New York State Adult Home Settlement presents a variety of systemic, care management, and individual member challenges. Adding the Pathway Home approach to an already existing, yet insufficient care management model strengthens the initiative's goal to transition and retain members safely into the community. Through the approach's adaptability and flexibility in providing community-based care, Pathway Home's successful cross-system collaboration is worthy of replication for other high need populations.

Implications for case management practice: A programmatic review for Pathway Home Adult Home+ teams gleaned the following key points for the field to consider in future care management practices. Class member self-efficacy and cross-system collaboration are essential in facilitating a class member's move into the community. Member choice and educating class members on their rights to move and options as well as community exposure prior to transition are important in assessing how a member fares outside of the Adult Home. Members determining their own care can reduce the risk of adverse outcomes and reinstitutionalization. Current low-touch care management programs are insufficient for members with complex needs living in institutions. These care management programs need to be augmented with a whole person approach, delivered by a multidisciplinary team.