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Substudy 6 Executive Summary


Substudy 6: Decision Making Processes of Assessors/Case Managers

by Denise Alcock, Nancy Edwards, Elizabeth Diem, Douglas Angus


Decision Making: Home Care or Facility Care is one of a number of studies which are part of the National Evaluation of the Cost-effectiveness of Home Care project. Decisions related to home care versus facility care and the type and frequency of services offered through home care are influenced by case managers who assess client and family needs, plan, implement and monitor services. In order to 1) better understand the factors which determine if long term care clients will be cared for at home or in a facility; 2) examine the extent to which home care and facility care are substitutable and 3) identify the factors which influence clients in a long term care facility to return home, data were collected through focus groups and questionnaires from 89 case managers in urban and rural regions of five provinces in Canada. Content analysis of the qualitative data collected allowed for an in-depth view of issues and factors related to decision making. These factors were grouped according to the case management decision making conceptual model of Alcock et al (1998) under organizational, system, client, informal provider, formal provider and case manager factors. An additional factor was generated by this study which was named ethical issues.

A wide range of factors promote the choice of care at home as opposed to care in a long term care setting. Organizational and system factors were reported across the five provinces as important factors influencing decisions. These range from public awareness of the provincial and regional policies and guidelines related to long term care; access to housing which accommodates for mobility problems, and is co-located with supportive services; to supportive communities (volunteers, meals on wheels, elder watch). Transportation for the elderly and disabled is a national issue. Day programs which provide health interventions, health monitoring, socialization and evening programs which provide respite care are under-utilized because of transportation difficulties. The financial well-being of the client or family is a factor in that home support services enable clients to remain in their homes and in some provinces these services are all or in part, the financial responsibility of the client or family. The lack of continuity of home support workers has influenced the decision of elderly clients to move into a nursing home because they cannot adjust to a continuous stream of different care providers in their home. Influences on home care versus placement decisions are discussed in depth under each of the following organizational, system, client, informal provider, formal provider, case manager and ethical factors.

Case managers across Canada agreed that the majority of long term care clients are appropriately placed and that there are not enough long term care facilities. However, valuable insight was gained into avoidance of early admission to long term care facilities and situations which influence the return of clients from facilities to their homes.

This report concludes with a proposed set of short term (1-2 years), medium term (3-4 years) and medium to long term (4 years or more) goals. Meeting these goals will improve not only access to care and quality of care for long term care clients, but will also contribute to a more efficient system which will contribute to the cost-effectiveness of long term care in the home and in facilities.