The purpose of this article is to discuss the "care management" (in the U.S. termed Managed Care) as it is implemented and practiced in Great Britain. Challenges to this needs-led service are discussed along with the responses to these challenges. Suggestions are made that would ensure a more client-focused implementation of care management.
Keywords: Decision Making, Needs Assessment; Managed Care Progs.; Patient Assessment; United Kingdom; Pt Centered Care
Introduction
CareManagement(intheU.S.termed"ManagedCare")washeraldedintheUKseveralyearsagoas"thecornerstoneofhighqualityservices"
Priortotheimplementationofcaremanagementin1993muchdiscussiontookplaceonexactlywhat"needs-ledservice"meant.Aneeds-ledservice?Thefundamentaldifferencebetweenthetraditionalservicesandonewhichwastobeneeds-ledwasthepositionoftheclientsinrelationtothecareprocess.Intraditionalservicesthetaskwasseenasassessingclientsneedswithintheframeworkofservicesthatalreadyexisted.Theprioritywastouseexistingservices,i.e.,theexistingserviceswerethecentralfocusoftheapproach.Bycontrast,aneeds-ledserviceassessesaclient'sabilitiesindependentofserviceswhichalreadyexistandassesseswhetheradditionalservicesareneeded. Allneedsareidentified;thenitisconsiderediftheseneedscanbemetfromexistingservices,requirenewservicesorifitisnotcurrentlypossibletomeetthem.Ifnosuitableservicesareavailablefromwithinthemixedeconomyofcare,thenanunmetneedisrecorded.Theinformationonunmetneedsisthenusedtoplannewcontractsfromstatutoryorindependent(private/voluntary)serviceproviders.
ChallengestoaNeeds-LedService Therearefourchallengestoa"needs-ledservice."Firstisthechallengeofdefinitionofneed.Muchoftheliteratureoncaremanagementtalksaboutneedsasifthereisanagreedunderstandingofthetermwhichisnotthecase.Bradshaw(1972citedby Thecomplexityoftheconceptofneedisrecognizedincaremanagement Thisdefinitionsuggestsasecondandrelatedchallenge,namelythatcaremanagementintheUKisdesignedaroundtheconceptofa"prescribed"needs-ledservices.Theclientthusmayremaindisempoweredinthecurrentcaremanagementapproach.Althoughtheirviewsmaybesought,thedecisionsaremadebytheprofessionals.Ifprofessionalsandresourcesavailable--ratherthantheclient--decideprioritiesoftreatment,aneeds-ledservicecanbecomea"resourceled"service. Athirdchallengeinvolvesthestrategythatinfluencestheidentificationofclientneed,namelythecollectionofinformationaboutwhattheclientfeelshe/sheneeds.Oftentheprofessionalthendistinguishesbetweenwhatisa"realneed"andwhatisa"want,desire,orpreference."Onceagain,aresourcedrivenandprofessionaldeterminedserviceisdelivered.Althoughitisnecessarywithincaremanagementtoremainrealisticaboutwhatservicescanbeprovided,itisalsonecessarytonegotiatewithclients.Ifaclientstatestheirneedandthisneedisunmet,itgetsrecordedassuch.Disregardingsuchunmetneedsasunrealistic"wants,desiresorpreferences"restrictsinnovationandperpetuatespreviousservicestructures Theprecedingchallengeshingeonthecontinuedunequalbalanceofpowerbetweentheclientandtheprofessionals. Astudyoncaremanagementforpeoplewithlearningdisabilitiesidentifiedafourthandimportantchallenge.Thisstudyconcludedthatassessmentisoftenrestrictedtoimmediateneedswithoutconsiderationoflongtermaspirationsandneeds.Peoplewithlearningdisabilitiesarenotassistedintakingpartinthedecision-makingprocess,andtheircarer'sneedsareoftenignored RespondingtotheChallenges Themajorchangeofferedbycaremanagementwasthegreateractiveinvolvementoftheclientinallstagesofthecareprocess.Centraltothischangedroleistheprovisionofinformation.Despitetheprioritygiventotheneedforinformation,thiscontinuestobeanareathatrequiresurgentattention.Publicityinformationaboutcaremanagementisoftenwrittenbyprofessionalsfortheircolleaguesanditcontainsinformationthatprofessionalsviewasnecessary.Someofthisinformationisofbenefittotheclient,butotherimportant(attimesunpalatable)informationaboutchargesforservices,limitedprioritiesbeingrespondedto,andthestricteligibilitycriteriaforservicesareoftenomitted. Theinvolvementofpotentialclientsandfocusingofinformationtospecificclientgroupscouldhelprefinethecontentoftheinformationprovided.Substantialprogresshasbeenmadeintheproductionofinformationinavarietyoflanguagesandonaudiocassettes.Agapstillexistsintheproductionofinformationinpictorialformatforpeoplewithdifficultyintheuseoflanguage. ResearchinaHealthandSocialServicesBoardAreainNorthernIrelandfoundthatdespiteamajormailingcampaignofinformationleafletsaboutcaremanagementtoallresidencesinthearea,only12%ofrespondentsrememberedreceivingtheinformation Somethoughtmustgointothephysicalappearanceoftheleafletanditscontent,however,criticaltoitseffectivenessistheaccessibilityoftheleaflet.Leafletsmustbevisibleinfacilitieswhichareusedbythemembersofthegeneralpublicandaswellasspecifictargetingoffacilitiesusedbypotentialclients(peoplewhoareelderly,havementalhealthneeds,physicaldisabilitiesorlearningdisabilities).Whenpeoplehaveaccesstoinformation,moreeffectiveusecanbemadeofthevariousservicesduringassessment,planning,implementation,andevaluationofpackagesofcare. Educationandsupportforstaffandclientsarealsonecessaryifaneeds-ledserviceistoprevailoveraservicethatrespondsonlytoprescribedneeds.Thisincludesin-serviceandpubliceducationaboutproceduralguidelines,aswellasacrucialchangeinphilosophy,adifferentpositionoftheclient(intermsofpower),partnershipactivitieswithclients,supervisionofcaseload,andpositiveconstructivefeedbackonprogress. Onabroaderperspectiveservicestructuresmustconsidertheircontractsandhowthesecontractsmeetindividualneedsasopposedtowhatservicestheyprovide.Evaluationofserviceswithincaremanagementmustincludenotonlystructureandprocessmeasuresofservicequality,butalsoincludemeasuresofclientperceivedoutcomes.Clientsatisfactionandservicecoveragewillalsoprovideusefuldataforservicedevelopment LecturerinNursing,Nursing-SchoolofHealthSciences OwenBarrisaLecturerinNursingattheSchoolofHealthSciences,UniversityofUlster,Colerain,N.Ireland.HeiscurrentlytheoptionleaderforthespecialistpostregistrationcommunitylearningdisabilitiesnursingoptionwiththeBaccalaureateProfessionalDevelopmentinNursingprogram.Withinthisprogramheteachesa12-weekmoduleonCareManagement(intheU.S.termed"ManagedCare").Hisresearchinterestsfocusonservicesavailabletopeoplewithlearningdisabilitiesandtheirfamilies.Morespecifically,heisinterestedintheinvolvementandempowermentofpeoplewithlearningdisabilitiesintheCareManagementprocess. EvaluatingServiceQuality.SCOVO.Cardiff,NorthernIreland. Thisimageisdifferentfromtheprojectedimagethatoriginallywasputforth
UniversityofUlster,N.Ireland
Jordanstown,N.Ireland
ArticlepublishedJanuary6,1997
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