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Communication patterns between case management and contracted medical providers within the Social HMO

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Communication patterns between case management and contracted medical providers within the Social HMO

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COMMUNICATION PATTERNS BETWEEN CASE MANAGEMENT
AND CONTRACTED MEDICAL PROVIDERS
WITHIN THE SOCIAL HMO
by
Kari Lynn Nishimura
A Thesis Presented to the
FACULTY OF THE LEONARD DAVIS SCHOOL OF GERONTOLOGY
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the
Requirements for the Degree
Master of Science in Gerontology
August 1997
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UNIVERSITY OF SOUTHERN CALIFORNIA
LEONARD DAVIS SCHOOL OF GERONTOLOGY
University Park
Los Angeles, CA 90089
This thesis, written by
_________________Kari Lynn. Nishimura______________________________
under the director of h er Thesis Committee and approved by all its
members, has been presented to and accepted by the Dean of the Leonard
Davis School of Gerontology and the Dean o f:________________________
in partial fulfillment of the requirements for the degree o f
__________________ Master of Science in Gerontology
Dean
Dean
D ate April 27, 1997____________
THESIS COMMITTEE
0
Q
d Chairman
l 4 - /------
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TABLE OF CONTENTS
CHAPTER
1. INTRODUCTION
Definition of Terms........................ 4
2 . LITERATURE REVIEW
Population Demographics.................... 6
Long-Term Care.............................. 9
Health Care Systems........................ 11
The Social HMO.............................. 14
History................................ 15
Long-Term Care Benefits.............. 17
Case Management....................... 19
Integration and Communication......... 20
SCAN Health Plan............................ 22
Conclusion.................................. 23
3. METHODOLOGY
Research Design............................. 25
Sample....................................... 25
Instrument.................................. 26
Data Collection............................. 27
Data Analysis............................... 2 7
4. RESULTS
Demographics................................ 2 9
Contracted Providers....................... 3 2
Job Questions............................... 33
Other SHP Employees/Departments........... 34
5. SUMMARY AND DISCUSSION
Summary...................................... 3 9
Discussion.................................. 40
Study Limitations........................... 41
Future Implications/Conclusion............ 42
6. REFERENCES....................................... 44
id
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CHAPTER 1
INTRODUCTION
Reform of the United States system for financing health
care has become one of the most controversially debated
social policy issues of the decade. Of special concern for
many involved in health care policy has been the
restructuring of the health care delivery system to meet the
unique needs of the changing older population.
It has been projected that by the year 2050, 68.5
million older adults (those 65 years of age and over) will
represent 22.9% of the total population, with the "oldest-
old (those 8 5 and over)" being the fastest growing age group
(US Bureau of the Census 19 92). This increase in the
average age of the population is expected to increase health
care spending, as the consumption of health care services
rises dramatically with age (Aaron 1991).
For most older individuals, acute and chronic
conditions and disability are experienced concurrently
(Leutz, Greenlick, and Capitman 1994). Chronic disease
among the elderly often results in functional impairment
which compromise independence and places the individual at
risk for institutionalization. Thus for older individuals
with chronic disease and disabiity, maintaining independence
within the community requires attention to acute medical
care as well as community based, long-term care services
which will address their functional deficits.
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Throughout health care reform debates, although long
term care has been prominently discussed, in the end long
term care benefits remain separate from acute care benefits
(Leutz, Greenlcik, and Capitman 1994). While Medicare
(parts A & B) and Medicare risk HMO1 s (those authorized
under the Tax Equity and Fiscal Responsibility Act of 198 2)
provide older individuals with medically necessary, short
term acute care services, they do not cover community based
long-term care.
The Social HMO (S/HMO) model was developed in the early
1980's at the Institute for Health Policy at Brandies
University. Since becoming operational in 1985, the Social
HMO demonstrations have shown that community based chronic
care can be successfully integrated with acute care for the
elderly at a manageable cost (Leutz, Greenlick, and Capitman
1994) .
The key to successful integration of acute and long
term care services within the Social HMO has been that of a
team approach to care coordination for frail elderly
members. The primary goal of case management within the
Social HMO is to prevent premature institutionalization
through care coordination and the authorization of long-term
care benefits (such as personal care assistance, homemaking
services, home delivered meals etc.) in conjunction with
medical benefits (Macko et al. 1995) .
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In order to ensure a smooth continuum of care, the case
manager must work closely with frail clients, their
families, primary care physicians (PCP's), discharge
planners, Utilization Review staff and contracted community
based vendors/home care providers.
Macko et al (1995) suggests that the case manager
within the Social HMO must possess the skills of
communication, relationship building and synthesizing
information from other members of the health care team in
order to develop a plan of care that will effectively meet
the needs of the frail client. In home long-term care plans
must respond to the older individuals fluctuating medical
conditions and subsequent functional changes (Abrahams
N.D.). The case manager must be able to elicit the
cooperation of other members of the health care team
(family, physicians, hospital staff etc.) as well as access
information (medical, functional, psycho social) that would
otherwise be unavailable to outside case managers.
Effective communication between case management and
providers in both acute and long-term care systems is
critical in ensuring timely responses to the frail client's
changing needs (Macko et al. 1995).
While the literature indicates that communication
between case managers and acute medical care providers is
essential in meeting the Social HMO's goal of integrating
acute and long term care services, there has been little or
no attention given to the case managers perception of actual
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4
communication patterns. The purpose of this study is to
explore the role of the Social HMO's case manager by
examining how the case manager perceives his/her role and
investigating communication patterns between case management
and contracted medical providers. In order to obtain data,
the researcher surveyed case managers within the Extended
Home Care department of SCAN Health Plan, one of the four
original Social HMO sites.
Definition of Terms
The following terms will be operationally defined for
use throughout this study.
Managed Care
Managed care is a term used to encompass various forms
of prepaid and managed fee-for-service systems designed to
control access to and cost of health care. Managed care
systems are characterized by a provider network, specific
service benefits to enrollees, specified compensation for
providers, and systems for authorizing care. Managed care
systems focus on providing comprehensive medical services
while providing incentives to manage/contain the utilization
and cost of services.
Health Maintenance Organization (HMO)
HMO's are a form of managed care by which health care
services are provided to an enrolled population by
contracted medical providers (medical groups and hospitals)
in return for a pre-paid fee.
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Extended Home Care (EHC)
Extended Home Care is used to describe community based
long-term care benefits offered by SCAN Health Plan (SHP) ,
one of the original four Social HMO sites.
Resource Manager (RM)
Resource Manager (RM) is the term used to describe the
Case Manager at SCAN Health Plan. The Resource Manager is
responsible for assessing frail health plan members for
eligibility for Extended Home Care benefits, as well as
administering the Extended Home Care benefits offered by
SCAN Health Plan.
£
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6
CHAPTER 2
LITERATURE REVIEW
Population Demographics
Since the turn of the century, the number of older
adults in the United States has increased more rapidly than
the general population (Longino, Manton, and Soldo 1990).
In 1900, individuals 65 and over comprised only 2.9% of the
total population. By 1977, these figures had more than
tripled with those 65 and over making up 12% of the nations'
citizens (Soldo and Agree, 1988). By the year 2030, it has
been projected that older individuals (those 65 and over)
will represent 21.2% of the total population (US Bureau of
the Census 1987). The ever increasing number of older
individuals has greatly impacted health care systems in
recent years and will continue to shape health care policy
and programs in the future.
In addition to an increase in the number of older
adults within the total US population, changes in age
composition of the older population are expected as well.
The older population has often been divided into three
categories - the young-old (65-74), the middle-old (75-84)
and the oldest-old (85 and over). In 1960, the young old
comprised 66.2% of the total older population.
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By the year 2000, it is projected that those 75 and under
will have dropped to 50.5% of the older population while the
oldest-old, the fastest growing age group will have
increased from 6% in 1960 to 14.7% of the total older
population (US Bureau of The Census 1992).
Despite widely believed stereotypes and myths about
aging, the elderly remain an extremely diverse and
heterogeneous population. In addition to changes in the
chronological composition of the older population, it is
necessary to examine the variability in qualitative factors
among older adults. Neugarten (1982) suggests that society
should view age as irrelevant stating that it is not
chronological age that is important , but rather the health
status and social characteristics of the elderly. The major
problems of older individuals are not acute illnesses, but
chronic conditions such as arthritis, diabetes and
hypertension, which affect functioning (Gelfand 1993).
Functional difficulties are based on the ability or
inability of an individual to perform basic Activities of
Daily Living (ADL's) which include walking, bathing,
dressing, grooming, eating, transferring and toileting and
Instrumental Activities of Daily Living (IADL's) including
meal prep, housework, laundry, shopping, telephoning, travel
and medication management.
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According to the National Medical Expenditures Survey (Leon
and Lair 1990) of 1987, 12.9 % of older individuals report
having difficulty with at least one ADL while 17.5% reported
difficulty with at least one IADL.
In a second large scale survey conducted by the US
Bureau of the Census in 19 90 , 8 5% of the elderly reported
having some chronic condition which limited the activity of
47% of older individuals living within the community.
Although there were age differences among individuals who
reportedly needed assistance with ADL's, consistent across
all of these differences was the greater need for assistance
among the oldest-old cohort. Chronic disease and
functional disability are interrelated and both increase
with age. According to the National Center for Health
Statistics (1989), approximately 3-5% of those age 65-74
required assistance with some ADL/IADL. By age 85 and over,
more than 20% needed assistance with bathing, 25% needed
assistance with shopping and more than 15% required
assistance with housework and meal preparation. While it is
true that as a cohort grows older, the incidence of acute,
short term illness declines and chronic conditions affecting
functional levels become more prevalent, it is important to
keep in mind that these changes do not necessarily accompany
aging for each individual within the cohort.
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9
Long Term Care
Long-term care services are targeted to those
individuals who have chronic, complex health problems and
subsequent functional deficits. Long-term care refers to a
broad spectrum of services ranging from institutionally
based medical and residential care to community based, in
home assistance. One definition of long-term care states
that:
Long-term care consists of those services designed to
provide diagnostic, preventive, therapeutic,
rehabilitative, supportive and maintenance services in
a variety of institutional and non-institutional
settings, including the home, with the goal of
promoting the optimum of physical, social and
psychological functioning(Koff 1982).
Kane & Kane (1982) define long-term care as:
A range of services that address the health, personal
care, and social needs of individuals who lack some
capacity for self-care. Services may be continuous or
intermittent but are delivered for a sustained period
to individuals who have a demonstrated need, usually
measured by some index of functional dependence.
As mentioned earlier, chronic diseases are often
accompanied by disabilities. The older an individual is,
the greater the likelihood of chronic conditions and
functional disabilities. Thus, as the number of old and
oldest-old increase so will the need for long-term care
services. Most long-term care services are provided
informally by friends and family members. Formal long-term
care systems have no single structure or source of
financing. Because long-term care is designed for those
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10
individuals who require ongoing services over an extended
period of time, an ideal system provides comprehensive,
integrated care that is able to change as the individual
needs change. The goal of long-term, chronic care is to
provide services that will promote or maintain health and to
enable the individual to maximize his/her functional
independence, in contrast to the goal of acute care that is
to "cure" an individual of an illness.
The ideal system of long-term care has been referred to
as a continuum of care that is defined as:
a client-oriented system composed of both services and
integrating mechanisms that guides and tracks
patients over time through a comprehensive array of
health, mental health and social services spanning all
levels of intensity of care(Evashwick, 1987).
Services within the continuum of care include acute
inpatient care, ambulatory care services (e.g.physicians'
services, outpatient clinics, adult day care ), extended
inpatient care (skilled nursing facilities, transitional
care units ), home care (Medicare covered home health,
homemaking/personal care ), outreach programs which serve to
keep individuals connected within the health care system,
wellness programs (including health education and screening)
and housing for frail individuals including retirement
communities, board and care and other assisted living
facilities. Because the continuum of long-term care is so
extensive, it is unlikely that any single organization can
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offer a complete continuum of services for all of its
clients. Rather, it has been suggested that the goal of the
provider should be to facilitate access to needed long-term
care services.
Current long-term care systems have been characterized
by fragmentation and disarray. The provision of long-term
care to those with chronic conditions and disabilities has
been both complex and inadequate. Critics state that on a
broad scale, current long-term care systems are
disorganized, underfunded, highly regulated, too-costly and
do not consistently meet the needs of its consumers or
providers (Evashwick 1993). The need for long-term care
services will increase exponentially in the coming years.
Long-term care spending is expected to increase from $5 9
billion in 1991 to $130 billion by the year 2000 (Kenkel
19 93). Due to limited health care resources, in order to
meet the increasing demand, current long-term care systems
must become integrated and evolve into a well-organized,
efficient, client-oriented continuum of care (Evashwick
1993) .
Health Care Systems
As with the current long-term care system, the United
States Health Care System is not really a "system" but a
"patchwork of loosely connected financing mechanisms varying
by provider type and reflective of age, health and economic
status of the specific patient groups that are being served
(Kotch 1993)." In terms of the United States General
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12
Public Expenditures, health care is the third greatest
expense following national defense spending and education.
Health care has become the largest service industry in this
country. In 1990, Americans spent $666 billion on health
care, comprising 12.2% of the GNP, amounting to $2,566 per
capita spending. Prior to World War II, only 4% of the
GNP was spent on health care. With the implementation of
Medicare and Medicaid in the 1960's, health care
expenditures rose from 6.3% of the GNP to the present figure
of 12.2%.
Such increases in health care expenditures have been
the result of a variety of qualitative and quantitative
factors. These factors include (a)the extension of third-
party payment through private insurance and public programs,
(b) an increase in the relative price of medical services,
(c) the aging of US population, and (d) malpractice and (e)
technological advances (Aaron 19 91).
Medicare, which provides physician and hospital
services to individuals 65 and over, is currently the
governments fastest growing program at 10% a year
(Rosenblatt 1995). Current policy makers have encouraged
the enrollment of Medicare beneficiaries into managed care
plans/Health Maintenance Organizations (HMO's)with tighter
spending controls in order to slow or at least limit
Medicare's annual growth rate.
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In order to do this, HMO's holding Medicare risk-coatracts
with the Health Care Financing Administration receive 95% of
Medicare's standard reimbursement, or what would normally be
spent on beneficiaries in the local fee-for-service system.
Medicare risk HMO's authorized under the Tax
Equity and Fiscal Responsibility Act (TEFRA) of 1982 are
mandated to provide its members all of the medical services
which are normally covered under Medicare part A (hospital)
and B (physician). Through capitated payments per member
per month from the Health Care Financing Administration
(HCFA) which oversees Medicare, Medicare HMO's can offer
members all that fee-for-service Medicare does but at a
lower out of pocket cost. Additionally, Medicare risk HMO's
offer benefits not covered by Medicare such as prescription
drug coverage, dental and vision benefits.
There are currently 35 million individuals (those 65
and over plus the disabled of all ages) receiving Medicare
benefits. In recent years, Medicare HMO membership has
increased substantially, with approximately 4 million
Medicare beneficiaries enrolled in a Medicare HMO in 1995,
up from 2 million in 1990 (Health Care Financing
Administration, Office of Managed Care, HMO Magazine
September/October 1995). Additionally, according to HCFA,
approval to form Medicare HMO's has risen dramatically in
recent years. The percentage of HMO's with Medicare risk
contracts has increased from 14% in 1991 to 23% in 1995
(GHAA's National Directory of HMO's Database - Whitmore*).
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The Social HMO
Although Medicare HMO's provide short-term acute
medical services, they do not cover community based long
term care. The late Rep. Claude Pepper (D-FL) introduced
the idea that both acute medical care and long-term care can
be strengthened if their provision is closely linked
together. Recent proposals, such as the Clinton plan and
the McDermott/Wellstone plan (advocated by Rep. Jim
McDermott (D-WA) and Sen. Paul Wellstone (D-MN) , have
proposed the addition of coverage for long-term care in both
nursing homes and in the community. In spite of pressure
from the American Association of Retired Persons (AARP) ,
various lobby groups and many House Democrats, the final
judgment was that a long-term care benefit would prove both
too costly and too difficult to manage (Iglehart 198 9) .
Over the past decades, numerous attempts have been made
to quantify the benefits of community based, long-term care
for the elderly and to assess its costs based on the
assumption that such care could save money by substituting
for institutional care (Leutz et al. 1992). While many
studies have shown that long-term care services for the
frail elderly in the community could be increased, these
services have usually raised overall health care costs and
have seldom reduced hospital or nursing home utilization
(Capitman 1989) . To date, Medicare experiments have yielded
little in the way of making community based long-term care
benefit programs available to the general Medicare
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15
population. Of the many demonstrations and experimental
models, only two have endured - the OnLok demonstration (and
the authorization of subsequent PACE sites) and the Social
Health Maintenance Organization (SHMO), both under
congressionally mandated Medicare/Medicaid
waivers(Leutz et al. 1992).
History
The Social HMO model, developed in the early 1980's at
the Institute for Health Policy at Brandeis University and
supported by the Health Care Finance Administration (HCFA) ,
was designed to bridge the gap between acute medical and
community based long-term care. The Social HMO
demonstrations expand its coverage to include not only what
Medicare and Medicare risk HMO's cover, but also community
based long-term care, thus integrating payment for acute and
chronic care services. The original four Social HMO sites,
Seniors Plus (Minneapolis, MN), Kaiser Permanente's Medicare
Plus II (Portland, OR), Elderplan (Brooklyn, NY) and SCAN
Health Plan (Long Beach, CA) became operational in 1985 and
were running at full financial risk by 1987.
The long-term care services offered by the Social HMO,
often called Expanded Care benefits or Extended Home Care
benefits depending on the SHMO site, were designed to
maintain functionally impaired members as independently as
possible within the community.
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Expanded Care or Extended Home Care benefits include: case
management, personal care assistance, homemaking services,
respite care (both in home and in patient),adult day care,
home delivered meals, electronic monitoring systems and
limited nursing home care (non-Medicare covered).
Financing for the Social HMO's long-term care benefits
come from a combination of Medicare, which pays 100% (versus
95% for TEFRA HMO's) of the adjusted average per capita cost
(AAPCC) for the locality, member premiums (not applicable at
some sites), co-payments for certain services and acute care
savings from efficient use of hospitals (Leutz et al 1992).
In order to compensate for the higher medical costs of
members who are deemed to be Nursing Home Certifiable
(criteria varies by state) , thereby qualifying for long-term
care benefits, the Social HMO receives a higher
institutional rate which amounts to almost double the
overall AAPCC.
Because the Social HMO offers long-term care benefits
that are not offered by its competition in the Medicare
supplement market, it has been suggested that the Social HMO
may be subject to adverse selection, as these benefits are
particularly attractive to Medicare beneficiaries who are
already disabled (Leutz et al 1988). In order to ensure an
enrollment similar to that of the general Medicare
population, Social HMO sites have employed enrollment
strategies which deliberately limit the proportion of
members who are functionally at risk for long-term care.
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Because the Social HMO enrolls a wide range of older
individuals, from the healthy to the severely disabled,
timely identification of frail members is critical (Macko et
al. 1995). All new members receive a self-report
questionnaire called the Health Status Form (HSF) at the
time of enrollment and annually thereafter (Re-HSF) to
identify members who may potentially be eligible for long
term care benefits. Other sources of referrals for benefits
include family, friends, physicians, hospital discharge
planners and health plan members themselves.
Long Term Care Benefits
In order to qualify for long-term care benefits,
members must be deemed Nursing Home Certifiable (NHC, which
varies by state) based on functional disability/ADL
deficits. Figure 1 details case management procedures at
SCAN Health Plan, one of the four original Social HMO sites.
SCAN Health Plan members who meet eligibility criteria for
admission to a skilled nursing facility or intermediate care
facility as defined in Title 22, California Administrative
Code, are deemed to be Nursing Home Certifiable (NHC) and
therefore qualify for Extended Home Care benefits. The
initial determination is made following completion of the
Comprehensive Assessment Form (CAF) by an Extended Home Care
Resource Manager (RM), who assesses the member in their
home. The CAF includes an extensive evaluation of the
member's medical history, functional deficits
(ADL's/IADL's), psycho social needs, living arrangements and
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Client Pathway
(Figure 1)
No— *)
Y«s
EMC l
NMC
bfCHC
CAF i
CM
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19
support system. The RM then develops a care plan working
closely with contracted medical providers(including
physicians, hospital discharge planners, home health
etc.),in order to meet the specific needs of the frail
member. The RM closely monitors the member's needs and
adjusts the plan of care and services accordingly.
Demonstration protocols require that NHC status be
reassessed every 90 days.
Case Management
The primary goal of the case manager (RM) within the
SHMO is to prevent premature institutionalization of frail
members through coordination with acute care providers and
the authorization of Extended Home Care benefits. SHMO's
have shown the ability to increase access to nursing home
care for respite and recuperation as well as the potential
to decrease permanent institutionalization and Medicaid
spend down rates (Macko et al. 1995). Kaiser Permanente's
SHMO site was able to decrease the number of members
spending down to Medicaid by approximately 50% compared to
Kaiser's TEFRA Medicare risk members who did not have access
to long-term care benefits (Boose 1993).
Communication between case managers and other members
of the health care team, including primary care physicians,
discharge planners and nursing home staff, is critical in
administering SHMO long-term care benefits and successfully
maintaining frail health plan members in their homes (Macko
et al 1995). The case manager focuses on the medical basis
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20
for functional impairments and recognizes the ongoing
community based long-term care needs of frail members with
complex, chronic medical conditions and thus adjusts long
term care plans to meet the frail individuals needs.
Because of this, the case manager must serve as a link
between members of the health care team and support all
members of the health care team in fulfilling their
traditional roles as providers of medical care so as to
achieve the shared goals of acute and long-term care
integration (Macko et al. 1995).
Integration and Communication
The SHMO was designed to provide a smooth continuum of
care for frail older individuals by offering a range of
benefits through a single organized system with the specific
goal of integrating acute and long-term care services
thereby decreasing fragmentation. Recent studies indicate,
however, that there is a lack of coordination between SHMO
case managers and physicians within the SHMO (Yordi 19 92) .
Underlying coordination problems are issues of
communication. For example, a study by evaluators for the
Health Care Finance Administration found that communication
between SHMO physicians and case management was limited and
was generally initiated by the case manager rather than
physicians (Harrington, Lynch, and Newcomer 1993) . In this
study by Harrington and colleagues, interviews with SHMO
physicians were conducted over a 6-12 month period.
Respondents were asked to provide descriptive information on
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21
working roles and relationships with SHMO administration and
staff members, particularly the case management staff.
Results indicated that most physicians were not involved in
long-term care plans and were unaware when case management
and long-term care services were needed or provided.
Additionally, it was found that physicians did not utilize
case management resources, in part because they were not
familiar with such services. According to results of the
study, physicians only occasionally interacted with other
participants in the SHMO delivery system, including case
managers and community based long-term care providers. In
conclusion, it was found that coordination of medical
services with long-term care and case management services
were limited and that these limitations led to some problems
in terms of access, continuity of care and satisfaction
within the SHMO (Harrington, Lynch, and Newcomer 1993) .
Harrington and colleagues also contend that in order to
solve the problems of the frail elderly population, case
management as developed by the SHMO, requires a real
commitment by physicians to work with case managers.
In response to these studies, the developers of the
SHMO demonstration argue that successful integration of
acute and long-term care services within the SHMO cannot be
evaluated solely in terms of how often physicians and case
managers talked to one another or how extensively involved
in long-term care plans physicians were (Leutz et al. 1995).
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Furthermore, the developers of the SHMO model emphasize that
their definition of "integration," focuses on ensuring that
access to benefits, delivery of services and sharing of
clinical information in the acute and long-term care sectors
were closely coordinated to where the two systems
intersected, thus viewing integration as a systems
development issue(Leutz et al. 1995).
SCAN Health Plan
SCAN Health Plan (SHP) , a network-model HMO (an HMO
which contracts with multiple medical groups so as to serve
a large geographic area) and one of the four original SHMO
sites was formed by a community based case management agency
(Senior Care Action Network)in association with several
medical groups and community hospitals in Long Beach
California. In recent years, SCAN Health Plan has
experienced tremendous growth, expanding its service areas
to include most of Los Angeles and Orange counties, while
steadily moving into San Bernardino and Riverside counties.
In 1993, SCAN served 5,773 Medicare beneficiaries. As
of March 1997, membership had risen to 17,694. Within the
past year, SCAN Health Plan has expanded its network of
contracted medical providers to include over 5 0 medical
groups and more than 60 hospitals.
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Conclusion
Since becoming operational, the Social HMO
demonstrations have successfully provided Medicare
beneficiaries with acute medical services as well as
community based long-term care benefits. Social HMO sites
have successfully delayed or prevented institutionalization,
with 90 - 95% of its members who meet the criteria to be in
a nursing home still living in the community (Schwab 19 96)
Motivated in part by the success of sites such as SCAN
Health Plan's, in 1990, legislation was passed authoring six
new SHMO sites. These six new sites are: Contra Costa
County Health Plan (Martinez, CA) , Fallon Community Health
(Worcester, MA) , Rocky Mountain HMO (Grand Junction, CO) ,
C.A.C Ramsay, Inc. (Coral Gables, FL) , Health Plan of Nevada
(Las Vegas, NV) and Richland Memorial Hospital (Columbia,
SC) .
As each of the existing SHMO sites as well as the new
sites continue to expand its network of acute care providers
to serve a greater number of older individuals, issues
regarding the relationships between SHMO case managers and
contracted medical providers will need to be closely
examined in order to ensure that the unique long-term care
benefits offered by the SHMO are effectively administered in
conjunction with high quality acute medical care.
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24
This study will attempt to examine the case manager's
perceptions of his/her role, as well examine the
relationship between case management and contracted medical
providers within the SHMO.
X
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CHAPTER 3
METHODOLOGY
The purpose of this study is to explore the Case
Manager's perception of his/her role as well as the Case
Manager's perception of communication patterns between Case
Management and contracted medical providers within the
Social HMO. It is hypothesized that the results of the
study will indicate a perceived lack of communication
between Case Management and contracted medical providers.
Research Design
Due to the fact that there has been little research
done in this area, this study is an exploratory,
descriptive study designed to obtain data to examine the
Case Manager's job perceptions as well as perceptions of
actual communication patterns with contracted medical
providers.
Sample
The targeted sample population for this case study was
Resource Managers employed by SCAN Health Plan (SHP), one of
the four original S/HMO sites based in Long Beach, CA, thus
employing non-probability/non-random, purposive sampling
methods.
Consent from SHP Administration was obtained prior to
the recruitment of potential subjects- At the end of a
weekly staff meeting, a questionnaire designed by the
researcher was distributed to 25 Resource Managers who were
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26
given Che opportuniCy to voluntarily participate in the
study by completing the questionnaire.
Instrument
Data were collected through confidential self-
administered questionnaires designed by the researcher. The
questionnaire was divided into three categories focusing on
the Resource Manager's perceptions regarding: (1)
contracted medical providers, (2) the Resource Manager's
role and (3) working with other SHP departments.
The 25 statement questionnaire utilized a 4-point
Likert-type scale with the following response choices: 1 =
all of the time. 2 = most of the time. 3 = some of the time.
4 = never (categories 1 and 3)and 1 = strongly agree. 2 =
agree. 3 = disagree. 4 = strongly disagree(category 2).
The first 10 statements in category 1 were intended to
explore the Resource Manager's perceptions regarding
working/communicating with SCAN Health Plan's contracted
medical providers and their perception of the level of
knowledge about the SHMO's Extended Home Care benefits. The
next 10 statements in category 2 were designed to examine
the Resource Manager's personal feelings about their role
within the Extended Home Care Department and within SCAN
Health Plan. The final statements in the category 3 were
intended to measure the Resource Manager's perceptions
regarding working with other SCAN Health Plan Departments
and how this impacts the provision of Extended Home Care
benefits to frail health plan members. Demographic questions
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27
were included to obtain simple demographic characteristics
of the targeted sample population. The researcher attempted
to keep the questionnaire brief to ensure the greatest
possible rate of return.
Data Collection
Potential subjects were given the option to voluntarily
participate in the study by completing the researchers
questionnaire. Each subject was given an informed consent,
a questionnaire and two legal size envelopes and was asked
to complete it without the assistance of another. The
researcher instructed the subjects to complete the
unidentified informed consent and questionnaire, seal them
in their separate unmarked envelopes and place the sealed
envelopes into boxes marked "Informed Consents" and
"Questionnaires," located in the researchers office - the
boxes were locked to protect the respondents anonymity. No
other employees had access to the completed materials.
Data Analysis
The data was analyzed using the "Statistical Program
for the Social Sciences (SPSS)" version 6.0. Due to the
nature of the questions contained in the survey and small
sample, the extent of statistical analysis was limited. The
data collected was qualitative in nature and as a result,
many statistical tests (such as regression analysis) were
not applicable. Although responses choices were coded
numerically, they had no quantitative value.
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28
SPSS was used to run frequency distributions as well as
Sheffe tests of significance between variables (such as
number of years working in case management, number of years
working with the elderly, number of years working at SHP)and
individual questions and categories of questions.
From the 25 eligible respondents invited to voluntarily
participate in the study, 22 respondents completed and
returned questionnaires, resulting in an 88% participation
rate.
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29
CHAPTER 4
RESULTS
This case study of SCAN Health Plan (SHP) was designed
to explore communication patterns between case management
and contracted medical providers within the Social HMO. In
addition to examining SCAN Health Plan's Resource Managers
perception of communication with contracted medical
providers, the surveys also examined the Resource Managers
perceptions regarding their roles within SCAN Health Plan,
as well as their perceptions regarding working with other
SCAN Health Plan Departments in providing Extended Home Care
benefits. Questionnaires were distributed to 25 Resource
Managers; 2 2 questionnaires were completed and returned to
the investigator.
Demographics
Demographic characteristics of the participants are
summarized in Table 1. Characteristics were stratified by
age; gender; education level; years working with the
elderly; years working in case management; and years
employed by SCAN Health Plan.
Frequency distributions are detailed in Table 1. All
of the respondents were female with an average age of 3 3.6
years. All of the respondents were college graduates with
41% of the sample holding post-graduate degrees. The
majority of the respondents (46%)had 5 or more years of
experience working with the elderly population and 32% had 5
or more years of case management experience. The majority
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30
of respondents (4 6%) were employed by SCAN Health Plan
between 1 - 2 years. Using the Scheffe test, there was no
statistical significance between each of the variables (age,
gender, education level, years working with the elderly,
years working in case management and years employed by SHP)
and each individual statement and categories of statements
contained in the questionnaire, at the 0.05 level of
significance.
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31
TABLE 1
DEMOGRAPHIC CHARACTERISTICS (N = 22)
Characteristics and Category
Age (Years)
<30 10 45.5
30-39 7 31.8
40-49 3 13.6
50+ 2 9.1
Gender
Male 0 0
Female 22 100
Education Level
Some College 0 0
College Graduate 13 59.1
Post-Graduate 9 40.9
Years working with the elderly
< 1 year 0 0
1 - 2 years 3 13.6
3 - 4 years 9 40.9
5 or more years 10 4 5.5
Years working in case management
< 1 year 2 9.1
1 - 2 years 7 31.8
3 - 4 years 6 27.3
5 or more years 7 31.8
Years employed by SCAN Health Plan
< 1 year 6 27.3
1 - 2 years 10 45.5
3 - 4 years 3 13.6
5 or more years 3 13.6
(tablelD.doc)
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Contracted Providers
Table 2 details the results of the survey. Responses
to the first category of statements indicated that SHP RM's
perceived that providers lacked knowledge about Extended
Home Care benefits. Responses also indicated that RM's
generally felt that there was a lack of communication
between RM's and contracted medical providers.
The majority (63.6%) of RM's stated that they felt that
UR staff, Case Managers and Social Worker's for contracted
medical groups were knowledgeable about SHP and EHC benefits
"some of the time," with 31.8% responding "most of the
time." Sixty-eight percent of RM's stated that Primary Care
Physicians (PCP's) were knowledgeable about EHC benefits
"some of the time," with 27.4% stating that PCP's were
"never" knowledgeable about SHP and EHC benefits. Fifty-
nine percent of RM stated that PCP's were aware "some of the
time" that clients/patients were receiving EHC benefits,
with 3 6.4% stating that PCP's were "never" aware.
Ninety-six percent of RM's surveyed stated that
hospital discharge planners, social workers and nursing home
staff contacted them "some of the time" to inform them of
admissions or discharges so that RM's could effectively plan
services for their clients. Forty-six percent of RM's stated
that PCP's contacted them "some of the time" to let RM's
know if they felt that clients/patients needed additional
EHC benefits, while 50% stated that PCP's "never" contacted
them. Furthermore, 45.5% of RM's stated that PCP's called
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to let them know of any information about clients/patients
that would be helpful in coordinating care "some of the
time," while 40.9% stated that PCP's "never" called.
Finally, 4 0.9% of RM's felt that there is enough
communication between RMs and contracted medical providers
"some of the time," while 40.9% felt that there was "never"
enough communication.
While it was generally felt that communication between
RM's and contracted medical providers was limited, it was
perceived that contracted providers were generally
cooperative in helping RMs to coordinate care for EHC
clients.
Job Questions
Responses to statements in category two indicate
general job satisfaction and a perception that EHC benefits
improve the quality of life for frail SHP members.
The RMs average case load was 48 clients. The majority
of RM's (54.4%) agreed that this was of a manageable size.
While 36.4% "strongly agreed" and 45.4% "agreed" that being
an RM is emotionally demanding, the majority (63.6%) of RMs
"strongly agreed" that being an RM gave them a sense of
personal satisfaction.
Sixty-four percent agreed that their clinical judgment
as an RM was valued by others in the EHC department. Fifty-
nine percent agreed that their clinical judgment as an RM
was valued by other contracted medical professionals.
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34
The majority (77.3%) of RMs agreed that they received enough
support from EHC staff in assisting them with complex or
difficult cases
Finally, 68.2% of RMs "strongly agreed" that the
benefits provided by EHC improves the quality of life for
SHP members. Furthermore, 77.3% of RMs "strongly agreed"
and 22.7% "agreed" that their clients considered them to be
a primary contact, not only for EHC benefits but also to
provide them with direction with problems or concerns in
relation to other SHP benefits.
Other SHP Employees/Departments
The final category of statements focused on the RMs
perceptions of the knowledge level of other SHP employees
regarding EHC benefits. In general, RMs perceived that
there was lack of knowledge about EHC benefits, but
perceived that employees in other departments were
cooperative in helping RMs to coordinate services for
clients.
Seventy-seven percent of RMs stated that employees in
other SHP departments were knowledgeable about EHC benefits
and criteria "some of the time," while 13.6% felt that they
were "never" knowledgeable. The majority (90.9%) felt that
employees in other SHP departments accurately convey
information about EHC benefits to SHP members "some of the
time," while 9.1% stated that they "never" accurately convey
this information. Sixty-eight percent felt that employees
in other SHP departments accurately convey information about
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35
EHC benefits to contracted medical providers "some of the
time." Finally, the majority (50%)of RMs felt that
employees in other SHP departments were cooperative in
helping them to plan or coordinate services for clients "most
of the time."
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36
Table 2 - Results
Category 1 - Contracted Providers
(I = ail of the time 2 = most of the time 3 = some of the time 4 = never)
1. Hospital discharge planners, social workers and nursing home staff call to let me know when my clients
are admitted or discharged so that I may effectively plan services for my clients.
2 = 4.5%(f = 1) 3 =95.5% (f = 21)
2. Utilization Review staff, case managers and social workers for contracted medical groups (e.g.,
Mullikin. Health Care Partners. Gateway etc.) are knowledgeable about Scan Health Plan and Extended
Home Care benefits.
2 = 31.8% (f = 7) 3 = 63.6% (f = 14) 4 = 4.5% (f = 1 )
3. Utilization Review staff, case managers and social workers for contracted medical groups are
cooperative in helping me to coordinate care for my clients.
1 = 4.5% (f = 1) 2 = 45.5% (f = 10) 3 = 50.0% (f = 11)
4. Primary Care Physicians are knowledgeable about Scan Health Plan and Extended Home Care benefits.
2 = 4.5% (f = 1) 3 = 68.2% (f = 15) 4 = 27.3% (f = 6)
5. Primary Care Physicians/office staff are aware that my clients are receiving Extended Home Care
benefits.
2 = 4.5% (f = 1) 3 = 59.1% (f = 13) 4 = 36.4% (f = 8)
6. Primary Care Physicians/office staff call to l et me know if they feel that my clients need additional
Extended Home Care benefits.
2 = 4.5% (f = 1) 3 = 45.5% (f = 10) 4 = 50.0% (f = 11)
7. Primary Care Physicians/office staff are aware of my role as a Resource Manager.
2 = 9.1% (f = 2) 3 = 59.1% (f = 13) 4 = 3l.8%(f=7)
8. Primary Care Physicians/office staff are cooperative in helping me to coordinate care for my clients.
2 = 40.9% (f = 9) 3 = 59.1% (f = 13)
9. Primary Care Physicians/office staff call me to let me know of any information about my client that
would be helpful in assisting me to coordinate care for my client.
1 = 4.5% (f = 1 ) 2 = 9.1 % (f = 2) 3 = 45.5% (f = 10) 4 = 40.9% (f = 9)
10. There i s enough communication between Resource Managers, Primary Care Physicians, hospital
discharge planners, social workers and other contracted medical providers to effectively and efficiently
care for f r ai l clients.
I = 4.5% (f = 1) 2 = 13.6% (f = 3) 3 = 40.9% (f = 9)4 = 40.9% (f = 9)
£
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37
Category 2 - Job Questions
(I = strongly agree 2 = agree 3= disagree 4 = strongly disagree)
1 . My case load of 48.15 i s of a manageable size.
1 = 22.7% (f = 5) 2 = 54.4% (f = 12) 3 = 22.7% (f = 5)
2. A home visit every six months and quarterly NHC’ s i s an adequate amount of contact for me to
effectively monitor my client’ s condition.
1 =4.5% (f = 1) 2 = 59.1% (f = 13) 3 = 36.4% (f = 8)
3. 1 feel that my clinical judgment as a Resource Manager i s valued by others in the Extended Home Care
department.
1 = 18.2% (f = 4) 2= 63.6% (f = 14) 3 = 18.2% (f = 4)
4. I feel that my clinical judgment as a Resource Manager is valued by other contracted medical
professionals (e.g.. other UR, discharge planners. PCP’ s ) .
I = 18.2% (f = 4) 2 = 59.1% (f = 13) 3 = 18.2%(f=4) 4=4.5%(f=l)
5. My role as a Resource Manager within SHP i s clearly understood by my client's and their families.
1 = 4.5% (f = 1) 2 = 68.2% (f = 15) 3 = 27.3% (f = 6)
6. My role as a Resource Manager i s emotionally demanding.
I = 36.4% (f = 8) 2 = 45.4% (f = 10) 3 = 18.2% (f = 4)
7. I feel that I get enough support from other EHC staff (supervisors, other Rm's etc.) in assisting me with
difficult/complex cases.
1 = 18.2% (f = 4) 2 = 77.3% (f = 17) 3 = 4.5% (f = 1)
8. I feel that the benefits (both in home services and case management) provided by Extended Home
Care improves the quality of life for frail SHP members.
1 = 68.2% (f = 15) 2 = 27.3% (f = 6) 3 = 4.5% (f = 1)
9. Being a Resource Manager and providing in-home services for my clients gives me a sense of personal
satisfaction.
1 = 63.6% (f = 14) 2 = 36.4% (f = 8)
10. I feel that my clients and family members consider me to be a primary contact, not only for Extended
Home Care benefits but to provide direction with problems or concerns in relation to other SHP benefits.
I = 77.3% (f = 17) 2 = 22.7% (f = 5)
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38
Category 3 - O ther Scan Health Plan Employees/Departments
(1 - all of the time 2 = most of the time 3 = some of the time 4 = never)
1. Employees in other Scan Health Plan departments ( e . g . . Marketing, Sales, Member Services) are
knowledgeable about Extended Home Care criteria and benefits.
2 = 9.1% (f = 2) 3 = 77.3% (f = 17) 4 = 13.6%(f=3)
2. Employees in other Scan Health Plan departments ( e . g . . Marketing, Sales, Member Services) accurately
convey information about Extended Home Care benefits to Scan Health Plan members.
3 = 90.9% (f= 20) 4 = 9.1% (f = 2)
3. Employees in other Scan Health Plan departments ( e . g . . Network Management, Member Services)
accurately convey information about Extended Home Care benefits to SHP contracted medical providers.
2 = 27.3% (f = 6) 3 = 68.2% (f = 15) 4 = 4.5% (f = 1)
4 . Employees in other Scan Health Plan departments ( e . g . . Member Services, Utilization Management) are
cooperative in helping me to plan/coordinate services for my clients.
I = 9.2% (f = 2) 2 = 50.0% (f = 11 ) 3 = 40.9% (f = 9)
A
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39
CHAPTER 5
SUMMARY AND DISCUSSION
This exploratory, descriptive case study attempted to
examine the Resource Managers perception of his/her roles
within the Social HMO as well as the Resource Managers
perception of communication patterns with contracted medical
providers. The results of this case study indicated that
RM's at SCAN Health Plan were satisfied with their jobs and
their roles within SHP. Consistent with the researchers
hypothesis, results of the study indicated a general feeling
that there was not enough communication between case
management and contracted medical providers.
Summary
In addition to RMs being satisfied with their job, RMs
also indicated that they felt that the EHC benefits offered
by the SHMO improved the quality of life for frail health
plan members. RMs generally felt that contracted medical
providers lacked knowledge about EHC benefits. Although it
was felt that communication was limited, RMs indicated that
overall, contracted medical providers were cooperative in
helping RMs coordinate care for EHC clients. Results also
indicated that while RMs believed that employees in other
SHP departments were limited in their knowledge of EHC
benefits, they were generally cooperative in helping the RM
to coordinate services for clients.
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40
Discussion
Results of this study support studies by Yordi
(1991)and other evaluators funded by HCFA, who found that
there was a lack of coordination between SHMO case managers
and physicians. Furthermore, results of this study support
the original study by Harrington (19 91), who found that
contact between SHMO physicians and case managers were
limited and that most physicians were unaware when case
management and chronic care services were needed or
provided.
One of the factors which may affect communication
between contracted medical providers and Resource Managers
at SHP, as well as contracted providers' knowledge level
regarding EHC benefits may be SHP1s rapid growth in
enrollment and subsequent addition of over 50 new medical
groups and 60 hospitals in the past year. Because SHP is
the only Social HMO site currently authorized in Southern
California, newly contracted medical providers may have
limited knowledge about the special benefits offered by the
SHMO.
Another factor affecting communication is that PCPs are
generally unaware when their patients are receiving Extended
Home Care benefits. There is currently no formal mechanism
in place for the RM to communicate the patients individual
Extended Home Care Plan and services that he/she receives to
the physician and his staff and to have this plan of care
noted in the patients medical chart.
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41
Limitations
Several limitations may have influenced the outcome of
this study. The size of the study sample was small.
However, the rate of return (88%)was good with 22 out of 25
questionnaires returned. The subjects in this study were
not randomly selected, which limits the ability to
generalize results of this study to case managers at other
SHMO sites. The researcher did not survey case managers at
other SHMO sites due to the fact that each SHMO site is
organized differently. For example Kaiser Permanente is an
established, staff model HMO which means that they employ
their own physicians and own their own hospitals. Staff
model HMOs may have an advantage over other HMO models in
their ability to "control and integrate the delivery of
medical services (Anderson et al. 1985). SCAN Health
Plan was a newly formed network model HMO which contracts
with multiple medical groups/IPA's affiliated hospitals.
The instrument utilized in this study may have been
unclear to some respondents or otherwise misinterpreted.
Because responses to statements contained in the instrument
were standardized, it did not allow for individualized
follow-up questions or responses. Finally, the instrument
was not tested for validity and therefore may not have been
appropriately designed to adequately assess perceptions
regarding communication patterns between Resource Managers
and contracted medical providers at SCAN Health Plan.
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42
Future Implications/Conclusion
SCAN Health Plan will continue to grow and expand its
network of contracted medical providers in order to serve a
greater number of seniors. Education of newly contracted
medical providers, as well as the continued re-education of
existing providers, will be critical in order to ensure that
acute care providers have a basic knowledge about the
special benefits offered by the SHMO and how to access these
benefits for their patients.
Resource Managers at SCAN Health Plan and case managers
at other SHMO sites will need to continue to develop their
communication and assessment skills in order to effectively
identify and meet the needs of their frail clients through
the appropriate provision of EHC benefits as well as working
in close contact with acute medical providers. Protocols
and mechanisms for involving the PCP in the Extended Home
Care Plan should be developed so as to facilitate
communication and integration of care between the Resource
Manager and medical providers.
Since becoming operational in 1985, existing Social HMO
sites have been subject to extensive review and criticism.
Formal HCFA evaluation indicated a lack of a geriatric focus
on medical care as well as a lack of involvement on the part
of physicians in the care of frail elders.
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43
Despite these criticisms, evaluations did show that
SHMOs were able to provide a comprehensive in-home benefit
far beyond what Medicare covers and are able to keep members
at home, thus avoiding long-term institutionalization
(Schwab 1996).
While there has been considerable debate regarding the
intended goals of the Social HMO demonstrations, the fact
that current SHMO sites, such as SCAN Health Plan, have been
successful in providing both acute and long-term care
services through a single organized system of care remains
undisputed. As our population continues to age, issues
regarding the long-term care needs of the elderly will
become more prominent. The Social HMO model may be looked at
as a possible nationwide option for the provision of
integrative acute medical and long-term care services.
Strengthening the links between Case Management and
contracted medical providers may serve as an important
strategy in facilitating care coordination for the frail
elderly within the Social HMO.
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44
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46
Leutz, W. , M.R. Greenlick, J. Ripley, S. Ervin, and E.
Feldman. 19 95. Medical Services in Social HMO's:
A reply to Harrington et al. The Gerontologist.
35 (1) , 6-8 .
Longino, C., B. Soldo, and K. Manton. 1990. Demography of
Aging in the United States. Edited by K. Ferraro,
Gerontology: Perspectives and Issues.
New York: Springer Publishing Company.
Macko, P., S. Dunn, M. Blech, F. Ashby, and T. Schwab. The
Social HMO's: Meeting the Challenge of Integrated Team
Care Coordination. Journal of Case Management. 4 (3),
102-106.
National Center for Health Statistics. 1989. Physical
functioning of the aged: United States. 1984. Series
10, Number 167. Washington, DC.-. U . S . Government
Printing Office.
Neugarten, B.L. 1982. Age or need in public policies for
older people? Beverly Hills, CA: Sage.
Rosenblatt, R.A. 1995. Republicans Devise Plan to Cap Open-
Ended Medicare Outlays. Los Angeles Times.
19 July (W).
Schwab, T.C. 1996. Social HMO's-. Lessons Learned and
Future Direction. Medical Interface. December, 10 6-
109 .
Soldo, B., and E. Agree. 1988. America's Elderly.
Population Bulletin. 43 (3) , Washington, DC. :
Population Reference Bureau.
US Bureau of the Census. 1987. Estimates of the
population of the United States, bv age, sex.
and race. 1980 to 1986. Series P-25, Number 1000.
Washington, DC.: US. Government Printing Office.
US Bureau of the Census. 1990. The need for personal
assistance with everyday activities: Recipients and
caregivers. Series P-70, Number 19. Washington,
DC.: US. Government Printing Office.
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
US Bureau of the Census. 1992. Current Population
Reports. Series P-23, Number 110. Washington, DC.:
US. Government Printing Office.
Yordi, C. 1991. Case Management Practice in the Social
Health Maintenance Organization Demonstrations.
Baltimore, MD: Health Care Financing Administration,
Contract no. HCFA 85-034/CA. 2nd Interim Report to
Congress: Evaluation of the Social/HMO Demonstration.
i
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
48
Informed Consent Letter
My name is Kari Lynn Nishimura. I am a candidate for the Master's o f Science degree in
Gerontology from the Leonard Davis School o f Gerontology at the University of
Southern California. I invite you to participate in my study of communication patterns
between case managers and contracted medical providers in the Social HMO.
If you choose to participate in this study, you w ill be asked to complete the attached
questionnaire. This should take approximately 15 minutes o f your time.
Your decision to participate is entirely voluntary. I f you decline or decide to withdraw
from the study at any time, you are free to do so without any negative consequences. The
study entails no foreseen risks.
Your responses will remain completely confidential and anonymous. Even when the
results of the study are reported, your name w ill not be revealed.
If you have any questions regarding the study, please feel free to contact me at 213-724-
9049. my thesis advisor. Dr. Jon Pynoos (213-740-1364) or committee member. Dr.
Kathleen Wilber (213-740-5156). Thank you for considering participation in this study.
If you agree to do so. please sign, print your name, and fill in the date below.
Signature: ________________________________
Printed Name:
Date:
i
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
49
QUESTIONNAIRE
INSTRUCTIONS:
I am conducting a survey on “Communication Patterns Between Case Management and Contracted
Medical Providers in the Social HMO.” The survey will take approximately 15 minutes of your time to
complete. Please read through the following statements and answer as accurately as possible. All of your
answers will remain anonymous. Thank you for your time.
£
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
j
50
DEMOGRAPHICS
Please provide the following information to help us gather demographic data. Any information you
provide will remain confidential.
1 - Age____
2. Gender
Male Female
3. Education Level
Some College____
College Graduate____
Post-Graduate____
(Master's or PhD)
4. Years working with the elderly
less than 1 year____
1 to 2 years____
3 to 4 years____
5 or more years____
5. Years working in case management
less than I year____
1 to 2 years____
3 to 4 years____
5 or more years____
6. Years employed by SCAN Health Plan
less than 1 year____
1 to 2 years____
3 to 4 years____
5 or more years____
i
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
51
Please respond to the following statements:
Category 1 - Contracted Providers
1 . Hospital discharge planners, social workers and nursing home staff call to let me know when my clients
are admitted or discharged so that I may effectively plan services for my clients.
a ll of the time most of the time some of the time never___
2. Utilization Review staff, case managers and social workers for contracted medical groups ( e . g . .
Mullikin. Health Care Partners. Gateway e t c . ) are knowledgeable about Scan Health Plan and Extended
Home Care benefits.
all of the time most of the time some of the time never___
3. Utilization Review s t a f f , case managers and social workers for contracted medical groups are
cooperative in helping me to coordinate care for my clients.
all of the time most of the time some of the time never___
4. Primary Care Physicians are knowledgeable about Scan Health Plan and Extended Home Care benefits,
all of the time most of the time some of the time never___
5. Primary Care Physicians/office staff are aware that my clients are receiving Extended Home Care
benefits.
all of the time most of the time some of the time never___
6. Primary Care Physicians/office staff call to let me know if they feel that my clients need additional
Extended Home Care benefits.
a ll of the time most of the time some of the time never___
7. Primary Care Physicians/office staff are aware of my role as a Resource Manager.
a l l of the time most of the time___ some of the time___ never___
8. Primary Care Physicians/office staff are coopertive in helping me to coordinate care for my clients,
a ll of the time most of the time___ some of the time___ never___
9. Primary Care Physicians/office staff call me to let me know of any information about my client that
would be helpful in assisting me to coordinate care for my client.
a l l of the time most of the time___ some of the time___ never___
10. There i s enough communication between Resource Managers, Primary Care Physicians, hospital
discharge planners, social workers and other contracted medical providers to effectively and efficiently
care for frail clients.
a l l of the time most of the time___ some of the time___ never
Ji
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
Category 2 - Job Questions
1 . My case load of i s of a manageable s i z e .
strongly agree agree disagree strongly disagree___
2. A home visit every six months and quarterly NHC’ s i s an adequate amount of contact for me to
effectively monitor my client's condition.
strongly agree agree disagree strongly disagree___
3. I feel that my clinical judgment as a Resource Manager i s valued by others in the Extended Home Care
department.
strongly agree agree disagree strongly disagree___
4. I feel that my clinical judgment as a Resource Manager i s valued by other contracted medical
professionals ( e . g . . other UR. discharge planners. PCP's).
strongly agree agree disagree strongly disagree___
5. My role as a Resource Manager within SHP i s clearly understood by my client’ s and their families,
strongly agree agree disagree strongly disagree___
6. My role as a Resource Manager i s emotionally demanding.
strongly agree agree disagree strongly disagree___
7. I feel that 1 get enough support from other EHC staff (supervisors, other Rm's e t c . ) in assisting me with
difficult/complex ca ses.
strongly agree agree disagree strongly disagree___
8. I feel that the benefits (both in home services and case management) provided by Extended Home
Care improves the quality of l i f e for frail SHP members.
strongly agree agree disagree strongly disagree___
9. Being a Resource Manager and providing in-home services for my clients gives me a sense of personal
satisfaction.
strongly agree agree disagree strongly disagree___
10. I feel that my clients and family members consider me to be a primary contact, not only for Extended
Home Care benefits but to provide direction with problems or concerns in relation to other SHP benefits.
strongly agree agree disagree strongly disagree___
with permission of the copyright owner. Further reproduction prohibited without permission.
Category 3 - Other Scan Health Plan Employees/Departments
1 . Employees in other Scan Health Plan departments ( e . g . . Marketing, Sales, Member Services) are
knowledgeable about Extended Home Care criteria and benefits.
all of the time most of the time some of the time never___
2. Employees in other Scan Health Plan departments ( e . g . . Marketing, Sales. Member Services) accurately
convey information about Extended Home Care benefits to Scan Health Plan members.
all of the time most of the time some of the time never___
3. Employees in other Scan Health Plan departments ( e . g . . Network Management. Member Services)
accurately convey information about Extended Home Care benefits to SHP contracted medical providers.
ail of the time most of the time some of the time never___
4. Employees in other Scan Health Plan departments ( e . g . . Member Services. Utilization Management) are
coopertive in helping me to plan/coordinate services for my clients.
all of the time most of the time some of the time never
JL
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

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Asset Metadata

Creator Nishimira, Kari Lynn (author)

Core Title Communication patterns between case management and contracted medical providers within the Social HMO

School Leonard Davis School of Gerontology

Degree Master of Science

Degree Program Gerontology

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag Gerontology,health sciences, health care management,OAI-PMH Harvest

Language English

Contributor Digitized by ProQuest (provenance)

Advisor [illegible] (committee chair), [illegible] (committee member)

Permanent Link (DOI) https://doi.org/10.25549/usctheses-c16-17409

Unique identifier UC11341093

Identifier 1387842.pdf (filename),usctheses-c16-17409 (legacy record id)

Legacy Identifier 1387842.pdf

Dmrecord 17409

Document Type Thesis

Rights Nishimira, Kari Lynn

Type texts

Source University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Access Conditions The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the au...

Repository Name University of Southern California Digital Library

Repository Location USC Digital Library, University of Southern California, University Park Campus, Los Angeles, California 90089, USA