Transcript Slide 1

EVALUATING INTEGRATED
SERVICES – AN APPROACH TO
IMPROVING CLIENT
OUTCOMES
Evaluating Integrated Services: An
Approach to Improving Client
Outcomes
Dr Pat Dorsett, PhD
School of Human Services and
Social Work,
Griffith University
November 2009
CRICOS Provider – 00233E
SCI Context
60 + people sustain spinal cord injury (SCI) per
year in QLD
Results in paralysis – quadriplegia or paraplegia
Requires long period of hospital based treatment
and rehabilitation
One SCI rehabilitation centre in Qld
Lifelong disability
Severe disruption to one’s life
The Spinal Cord Injury Response (SCIR)
Initiated in 2005/6 and fully operational in 2006/7
a collaborative, cross-agency response designed to support individuals
with new spinal cord injuries in their transition from hospital
rehabilitation to community through the co-ordinated delivery of a
comprehensive range of services
aims to reduce barriers to timely discharge from hospital, enhance
quality of life and increase community participation
Partners:
Disability Services Queensland (DSQ)
Queensland Health (through Queensland Spinal Cord Injuries Service – QSCIS – Qld Spinal Injuries Unit,
Transitional Rehabilitation Program and Spinal Outreach Team)
Spinal Injuries Association (SIA)
Department of Housing (DOH)
Home and Community Care (HACC)
Medical Aids Subsidy Scheme (MASS)
Response to community demands for improved services
Evaluation Methodology
Phase 1
Literature Review
A literature review of published research was conducted to
gain a thorough understanding of previous work in the
area, emerging trends and best practice standards in
transitional and community support services for people
with disabilities, particularly spinal cord injuries.
Phase 2
Organisational Impact Evaluation
An evaluation of the organisational impact of SCIR
including efficiencies and effectiveness for government
and interagency coordination was undertaken. This phase
of the research aimed at determining the nature and quality
of interagency communication in regards to service
delivery, quality of care and transitions of care.
Phase 3
Client Impact Evaluation
The objective of Phase 3 was to evaluate the effectiveness
of the SCIR model in meeting the transitional needs of
those with SCI. Service usage,context, effectiveness,
outcomes, satisfaction and quality of life were examined
using a mixed method qualitative and quantitative
approach
Phase 4
Cost Efficiencies of SCIR
The cost of hospital care plus community care was
calculated for a sub-sample of 8 SCIR clients and
compared to cost of a sample of 8 non-SCIR clients
including the first 6 six months post discharge from
hospital.
Phase 5
Service Profile
Data from each of the SCIR partner organisations was
collated to develop a profile of the SCIR since
commencement in 2005 until March 2008.
Relevant research articles identified from
the Medline, REHADAT and CINHAHL
databases
Included both quantitative and qualitative
studies
Key search terms: Spinal cord injury,
satisfaction, quality of life (QOL), transitional
care, integration, and coordination
9 Semi-Structured interviews with key
stakeholders
3 Focus Groups
Process Mapping
Network Analysis
The Partnership Effectiveness Rating Scale
The Levels of Collaboration Scale
24 SCIR and 14 non-SCIR participants
Craig Hospital Assessment and Reporting
Technique (CHART)
Terry Self-Efficacy Scale
Coping Measure
Life Satisfaction
Problems
Two matched groups
Hospital Length of Stay
TRP Length of Stay
Equipment Costs
Cost of Support Program
Cost of Home Modifications
.
Number of clients supported
Types of services provided
Hours of support provided
Cost of programs
Aids and equipment funded
Predictors of transition outcomes
Age, gender, marital status
Environmental accessibility
Personal mobility/transport
Independent living arrangements
Social support & social connectedness
Financial security
Vocational & leisure options (productivity)
Perceived health
Role of service systems in transitions
Paucity of research about integration of services
to support transitions
Transitions are known to be a significant problem
point in health-care delivery but are rarely studied
in detail.
Few health or social services are fully aware of
the intensity of the transition experience
Informal caring relationships (including family)
can be jeopardised by the fragmented and
uncoordinated service systems
Positive features of transitional services
Person centred & consumer directed
Addresses personal context and
environment
Co-ordination and continuity (holistic)
Focus on function
Individualised and empowering
Adequate resourcing to meet needs
Integrated services sound simple, but anyone
who has attempted to develop a partnership or
network will appreciate the level of complexity,
conflict and uncertainty that must be managed.
Two flawed assumptions, namely rationality and
altruism
Participants
10 senior management staff – Interviews – Outcomes and
benefits for clients and agencies, implementation processes;
3 Focus groups with 22 operational staff – process mapping
16 key staff - Survey – network analysis– level of
integration and collaboration, challenges, sustainability
21 SCIR and non-SCIR clients - interviews and surveys ––
problems, satisfaction, experiences
Level of Integration
93% of participants reported that a genuine partnership had
been established
Areas of Achievement (>90% consensus across participants):
The purpose of SCIR (i.e. clear and understood goals and purpose
that are shared in a vision)
its benefit (i.e. shared view of need and value, demonstrable
achievements that outweigh costs)
the level of investment in SCIR (i.e. organisation support, and to
promote SCIR)
the development of a network (i.e increasing interdependence
across organisations, a willingness to share information, good
relations, and participatory approaches).
Level of Integration
93% of participants reported that a genuine partnership had
been established
Areas for Improvement
formal structures and standardised procedures across organisations
(administration, communication, decision-making, informationsharing and resolving conflicts)
development of common ideologies, and approaches to practice
clear roles, communication strategies and expectations that are
understood by all
increased resources as a result of partnership
formal and informal opportunities for inter-agency contact and joint
workforce development
capacity to identify and minimise risks
Benefits/Costs for Staff
Ability to serve my clients better
100% already occurring or expected
Building new helpful relationships
93% already occurring or expected
7% not occurring and not expected
Acquisition of funding or other
resources
93% already occurring or expected
7% not occurring and not expected
Better use of organisation’s services
86% already occurring or expected
14% not occurring and not expected
Acquisition of new knowledge/skills
86% already occurring or expected
14% not occurring and not expected
Increased ability to allocate resources
71% already occurring or expected
29% not occurring and not expected
Loss of control/decision autonomy
14% already occurring or expected
86% not occurring and not expected
Difficulty in dealing with partners
36% already occurring or expected
64% not occurring and not expected
Enhanced influence in the community
64% already occurring or expected
36% not occurring and not expected
Takes too much time and resources
57% already occurring or expected
43% not occurring
Strained relations
57% already occurring or expected
43% not occurring and not expected
Integration cannot compensate for poor or
absent services!
“Coordination of care, for which personnel are
constantly striving but know they are not often
attaining, is something of a mirage except for
the most standardized of trajectories. Its
attainment is something of a miracle when it
actually does occur”.
Strauss et al., (1985)
SCIR Activity 2006-2008
80 SCIR clients
22 complete home modifications (none preSCIR)
20 allocated accessible houses
23 personal support packages (about 40
hrs/week)
89 referrals for specialised aids and
equipment
Outcomes of SCIR
Shorter LOS but greater identification of Needs
Reduced average hospital stay by 26 days at a saving of $773 per day (a
potential savings of $844K annually). Community supports (equipment,
personal care) was $35K more reducing savings to $556K annually.
Need for Personal Care Services met
Perceived sufficiency of care - 81% SCIR clients versus 63% non-SCIR clients.
Greater Life satisfaction
SCIR clients reported greater overall life satisfaction than non-SCIR clients
(Mann-Whitney U = 75, p<.01).
Fewer Health Problems
SCIR clients reported experiencing fewer ‘health problems’ than non-SCIR
clients (Mann-Whitney U = 70, p=.007). Trend towards significance for greater
sense of control (Mann-Whitney U =89, p=.043) and the fewer overall
problems (Mann-Whitney U = 91, p=.050).
Client experiences
Case Study # 1 Pre-SCIR Client
“You ask me what it was like when I first went
home. It was a horrible part of my life. I felt
like I had nothing. I felt like I could die.”
Case Study # 2 SCIR Client
“...as far as the carers were concerned . I was
a bit overwhelmed... Because I never knew
about all that help they were giving me. I
thought this is terrific! Thank God for that.”
Client Preferences
A Holistic Framework
Pay attention to holistic needs, including emotional and social
Work with other practitioners and natural support systems
Consumer-Driven Process
Recognise me as an expert and source of knowledge
Be “in-my-life” not just “in-my-home”
Understand my unique experience of disability in my daily life
Nothing about me without me
Appreciate my journey and its impact on rehabilitation
Promote Disability Awareness
Promote disability awareness in the community
Be proactive to reduce barriers in the environment and society
Client Preferences
A Seamless Process
Do not compartmentalise rehabilitation – it should be
one whole package
Begin early to prevent losses and crises
Share information with me and my family
Respond to my values, what is important to me over
time, and my changing needs
Ensure equitable access to services
Challenges for SCIR
Resources for Change (Change Management processes)
Lack of time, resources, clear information and change management strategies – cultures, resource
restrictions and capacity of the various organisations were not always understood
Pragmatic Constraints
Discharge processes and coordination was complicated by pragmatic challenges, such as
equipment availability, lack of housing options, and workforce issues especially in rural remote
areas.
Inter-Agency Communication at all Levels
Opportunity to share information about each other’s organisations and limitations, providing an
equitable forum for all partners to be heard, maintaining a system for monitoring processes and
outcomes and following-up on issues.
Balancing Competing Demands
Balancing client needs against available resources, managing client expectations, reconciling
simultaneous roles as funds-holders and client advocates.
Managing Workload Challenges
SCIR increased workloads, requiring changes to existing internal processes, increasing the need for
interagency communication and requiring the development of new ways of working together.
Responding to Future Needs
The ongoing needs of clients as they change over time. Early discharge and accurate needs
assessment, future needs may not be identified.
Retention of Key Staff Members
Clear and detailed changeover and orientation processes