Case management is a nursing care service delivery method and a “collaborative process of assessment, planning, facilitation, care coordination, evaluation, and advocacy for options and services to meet an individual’s and family’s health needs through communication and available resources to promote quality cost-effective outcomes” (Case Management Society of America [CMSA], 2010, p. 8). During case management, individual members of the community are assisted by knowledgeable and skilled healthcare professionals called case managers whose role is to manage and coordinate services that meet patient needs.
As has happened in many other countries, the Taiwanese healthcare system has adopted case management as a care delivery method. To care for community-based vulnerable populations, the Taipei City Government employs case management as a method to ensure that citizens obtain essential healthcare services. In this system, public health nurses act as case managers by providing links to services for people with mental illness and older adults living alone in the community (Taipei City Government, 2013). The role fulfilled by Taiwanese public health nurses has therefore changed, as they are now required to be case managers, with a focus on communication, coordination, and cooperation with other professionals (Dai, Chang, Lu, & Wu, 2004). The Taiwan Nurses Association (2012) established advanced community health nursing practice as a way to perform disease management, risk management, rehabilitation, and resource linking and utilization. Case management is one of the core competencies for advanced community health nursing. Public health nurses (PHNs) conduct needs assessments, service planning, service coordination, and monitoring for their clients. To achieve effective case management outcomes, PHNs must acquire new knowledge and skills related to case management. However, most PHNs in Taiwan do not receive case management education because of the limited number of available education programs.
Educational preparation is key to ensure case management success (Cohen & Cesta, 2005; Liu, Edwards, & Courtney, 2008). Continuing education or certification can ensure the quality of community health nursing (Chen, 2009). Increased case manager preparation and training is generally associated with better care outcomes at reduced cost and higher care quality (Barney, Rosenthal, & Speier, 2004; Powell & Tahan, 2008; Tahan & Campagna, 2010). Nurses require knowledge and training to perform effective and comprehensive case management; a review of the literature illustrates the types of knowledge required. The CMSA has identified knowledge of funding sources, healthcare services, healthcare delivery, and clinical standards and outcomes as foundational for case managers. The skills and knowledge base of a case manager may be applied to individuals or groups of clients (CMSA, 2010). Their recommendations are based on research by Chan, Leahy, McMahon, Mirch, and DeVinney (1999), who examined job activities and knowledge areas deemed essential for effective case management. Tahan and Campagna’s study also identified six knowledge area domains.
Case management can be seen as a compilation of roles and activities performed by a case manager within a particular healthcare system. However, several service components and management activities common to all case management models may be identified independent of care setting. The CMSA (2010) has drawn from a spectrum of case management practices and specialties to establish these standards. An activity is a discrete action or task performed to address the expectations of a role (Tahan & Campagna, 2010; Tahan, Huber, Downey, 2006). Activities relate to the identification and selection of clients for case management services, problem identification, planning, monitoring, evaluating, and assessing outcomes (CMSA, 2010; Cohen & Cesta, 2005). Each step of the case management process is associated with a set of activities conducted by the case manager. Anderson-Loftin (Flores, Reyes, & Pérez-Cuevas, 2006) developed an instrument describing case manager role activities. Activities related to clinical duties and teaching were identified by the author as the most frequently performed case management tasks, based on an assessment of 302 nurses and 27 role activities (Anderson-Loftin, 1996).
Taiwanese PHNs employed in government health offices are often required to act as case managers. Lack of available education in this context contributes to a gap in existing case management knowledge and preparedness levels. Little work has been undertaken to explore PHNs’ case management knowledge and preparedness levels or identify educational needs.
A cross-sectional study design was used to explore Taiwanese PHNs’ practical knowledge of and preparedness for case management. The target population is composed of all PHNs in the city of Taipei, Taiwan. At the time of testing, approximately 217 PHNs were employed in the 12 administrative districts of Taipei City. Each district had a single healthcare center employing 9–24 PHNs. Taipei City was selected for this study because it is the capital and largest city in Taiwan as well as the first to establish a health policy using case management for individuals with mental illnesses and older adults living alone in the community.
The names of each of Taiwan’s 12 government health offices were written, respectively, onto 12 cards, which were then folded to conceal the names. A neutral party randomly selected 10 of the cards. All registered PHNs in the 10 selected health offices were eligible for inclusion as participants. The remaining two centers were used to test the instrument and predict potential data collection problems. To ensure adequate participation, the researcher requested the support of the head nurses and district managers in each district. All 12 districts gave formal approval for their staff to participate in the study.
All nursing staff in the 10 targeted health offices were invited to participate. Those who had worked in Taipei City community government health offices for at least 3 months and concurrently cared for at least one older adult living alone or one patient with mental illness were enrolled as study participants.
Ethical approval was obtained from the ethics committee of National Taipei University of Nursing and Health Sciences. PHNs were given information sheets with detailed information about the study, and written consent was obtained from each participant. Participants were assured that their responses would remain anonymous and confidential.
The questionnaire used for data collection consisted of three sections: Section One featured 20 multiple-choice items. Section Two included case manager role activities. Section Three collected demographic information.
Case Management Knowledge Index
Section One of the questionnaire was the Case Management Knowledge Index, comprising questions addressing basic concepts and processes in case management. The multiple-choice items were modified from “A Case Manager’s Study Guide Preparing for Certification” (Fattorusso & Quinn, 2004), a set of published case management test materials. Permission to use this guide was obtained from the publisher. Eighteen multiple-choice items were selected from this resource. Some of the items were modified based on feedback from an expert panel to better address case management concepts and procedures.
Case Management Activity Scale
Section Two of the questionnaire measured the experience of participants in case manager role activities. Twenty-seven case manager role activities were rated on a 1–5 Likert-type scale from very low to very high. This instrument was based on Anderson-Loftin’s Nurse Case Manager Impact Profile Part II: Case Management Activity Scale (Anderson-Loftin, 1996). The original scale was composed of 39 items organized into four subscales that measured the frequency of nurse case manager activities in clinical practice (21 items), teaching (six items), research (six items), and system advocacy (six items; Anderson-Loftin, 1996). Selected activities were further reviewed by the expert panel and examined in the pilot study.
The original instrument was assessed for content validity and revealed a content validity index (CVI) of 95% (Anderson-Loftin, 1996). Construct validity was assessed using common factor analysis and the five factors of individual advocacy, clinical practice, teaching, research, and system advocacy. These five factors explained 47.8% of total item variance. In addition, Cronbach’s alpha coefficients of internal scale consistency were calculated as .93 (Anderson-Loftin, 1996).
In the current study, 27 of the items relating to clinical practice and teaching were included because these items addressed case management processes and case manager role-related activities. The items relevant to research and system advocacy were omitted because Taiwanese PHNs do not engage in these activities in case management practice. Case manager role activities were compared with PHNs current practice activities, further reviewed by the expert panel, and examined in the pilot study. Three items in the original instrument were modified because of their focus on hospital-based practice.
Instrument validity and reliability
Each of the selected instruments was available in English. All English-language-version instruments were translated into Chinese by one professional translator and a researcher and then translated back into English by two other professional translators. The two language versions were then compared to achieve semantic equivalence by two research team professors. The psychometric properties of these measures were established again through pilot testing with 26 participants from two districts selected at random. A panel of six experts generated a CVI. The CVI results indicated that the adapted versions of the knowledge and activity scales had CVIs of 0.87 and 0.97, respectively.
Internal consistency and test–retest reliability were the two reliability aspects assessed. The Kuder–Richardson 20 and Cronbach’s alpha coefficients of these measures were 0.52 and 0.96, respectively. Instrument stability was determined using intraclass correlation coefficients. The scales had statistically significant intraclass correlation coefficients ranging from .56 to .82 (p < .001) between Time 1 and Time 2 (2 weeks later). These results indicated that the adapted version of the knowledge and activity scales had satisfactory validity and reliability.
Data Collection and Analysis
Data were gathered from each health center. The researcher explained the study aim to participants before distributing the self-administered questionnaire. The Chinese-language questionnaire, consisting of three sections, required 20 minutes to complete. Data from all districts were collected using the same procedure and during the same time.
Data analysis was conducted using SPSS Version 19.0 (SPSS Inc., Armonk, NY, USA). Descriptive statistics were used to examine demographic and outcome variables. The mean and standard deviation were calculated for all continuous variables, including age, years of nursing practice, years in public health nursing, case management knowledge, and level of preparedness for case manager role activities. Percentages for dichotomous or categorical variables were also calculated, including gender, previous case management training, and highest educational level in nursing. T tests and one-way analysis of variance were applied to examine participant characteristics in relation to each variable, with α = .05 indicating statistical significance.
The target sample size was 217 PHNs. The two health offices with 26 PHNs randomly selected for the pilot testing were excluded from participation. Twelve head nurses did not meet the criteria because their work did not involve case management. One nurse declined to participate because of retirement plans. One hundred seventy-nine eligible PHNs were identified in the 10 districts, and 178 agreed to participate. The power estimate was 0.80 according to the 178 samples, with α = .05 and effect size = 0.5. Thus, the sample size for the study was sufficient to ensure scientifically valid results. One hundred seventy-eight participants completed the data collection instruments, with a 99% valid response rate.
Participants were all women with a mean age of 39.3 years, ranging from 24 to 55 years. Overall, nurses were quite experienced (M = 16.8) despite a high variance range of 0.5–35 years. Their experience in public health nursing (M = 8.6) ranged from 0.5 to 29 years. More than half (59%; n = 105) held diplomas, and 27.5% (n = 49) held a nursing bachelor’s degree. Most (82%; n = 146) had never attended case management training. Table 1 provides a summary of participant characteristics.
Case Management Knowledge
A score of 1 was recorded for correct responses, and 0 was recorded for incorrect responses. The 20 item scores were summed to obtain a total knowledge score that could range from 0 to 20. Mean participant knowledge score was 9.8 (SD = 2.8), equal to 49%, with scores ranging from 3 to 15. The results indicated that the participants had little knowledge of case management at the time of this study.
The lowest-score knowledge items, shown in Table 2, were the following:
- 1. The one role that allows case management practice to transcend all other disciplines is that of? (18.0%; n = 32, answered correctly)
- 2. In evaluating a community medical plan, what are the main considerations? (25.3%; n = 45, answered correctly)
- 3. What is a system of cost containment programs? (27.0%; n = 48, answered correctly)
- 4. A community case management plan is? (27.5% ; n = 49, answered correctly)
- 5. Identification of potential high-risk or high-cost patients is known as? (32.6%; n = 58, answered correctly)
Activity Preparedness for Case Management
The Activity Preparedness Scale rated participant preparation for performing various case manager role activities. All items were averaged to obtain the scale score. The mean participant preparedness score was 3.2 (SD = 0.5), with scores ranging from 2.1 to 4.5. Participants held neutral opinions regarding their perceived level of preparedness for performing case management activities.
Activity preparedness items scoring below average, shown in Table 3, were the following:
- 1. Participation in quality assurance activities, for example, monitoring or auditing client care (mean score: 2.8 [SD = 0.8]; 82% [n = 146] below-average level).
- 2. Participation in interdisciplinary service planning (mean score: 3.0 [SD = 0.7]; 82% [n = 146] below-average level).
- 3. Assist with financial matters such as insurance premium subsidies, allowances for medium- and low-income families, and medical equipment subsidies (mean score: 2.9 [SD = 0.8]; 80.3% [n = 143] below-average level).
- 4. Implement service plans, including the acquisition of medical equipment (mean score: 3.0 [SD =0.7]; 80.3% [n = 143] below-average level).
- 5. Collaborate with members of other disciplines to develop multidisciplinary care plans applicable to groups of patients (mean score: 3.0 [SD = 0.8]; 77% [n = 137] below-average level).
Influence of Participant Characteristics on Knowledge and Activity Preparedness
Characteristics including age, nursing experience, educational level, and prior training were unrelated to participant knowledge regarding case management (Table 1). Prior training was the only participant characteristic with a significant effect on activity preparedness (t = −2.97, p < .003*). These results indicate that training may affect the development of practical activity preparation.
In addition, this study unexpectedly found that segregating participant knowledge level into high and low groups resulted in significant difference between the two in terms of age; the group with a higher knowledge level was significantly younger. This may be because of better access to education for younger PHNs involved in case management courses.
The aim of this study was to explore PHNs’ knowledge and preparation levels related to case management. Participant knowledge scores in case management reflected substantial gaps in theoretical comprehension of case management, especially with regard to roles intended to coordinate all other disciplines, cost containment, and quality outcome evaluation. PHNs reported that they were not well prepared for case management activities, especially with regard to interdisciplinary collaboration, cost and quality assurance activities, acquisition of resources, and assisting clients with financial matters.
These findings are consistent with Smith’s (1998) research of nurse case manager confidence in handling critical activities. The lowest confidence was reported in coordinating transfers, understanding financial classifications, and delegating authority. These activities are considered to be different from traditional nursing process activities and are viewed as the key functions of case managers. Highlighting similar topics as imperative for the new case manager, Nolan, Harris, Kufta, Opfer, and Turner (1998) explored educational needs identified by case managers. Educational preparation is important to the success of an individual case manager and the survival of this new role in the healthcare system (Kulbok & Williams, 1999). When a nurse’s caregiver roles transform into those of a case manager, additional preparation and training is required (Schmitt, 2006).
The knowledge and role activity gaps identified in this study are attributable to the differences between the nursing process and case management. Nursing case management focuses on cooperation among other professionals, coordination and resource utilization, and integrated roles to ensure integrity of care (Liu et al., 2008). Cost containment and concerns about quality of care are leading healthcare institutions to consider case management to ensure that patients receive needed care and services and that those services are delivered in an efficient, high-quality, and cost-effective manner (Cohen & Cesta, 2005). These role requirements and the small percentage (18%, n = 32) of PHNs who have prior relevant training may explain why there are large gaps in their knowledge and preparation for case management.
This was one of very few studies to survey PHN knowledge of and preparation for the role of case manager in Taiwan. Some scholars argue that experienced PHNs can learn to act as case managers (Dornan, Boshuizen, King, & Scherpbier, 2006; Kemeny, Boettcher, DeShon, & Stevens, 2006). However, this study found that, although PHNs may have many years of informal case management experience, continued training is required as care systems change and career transfers become relevant.
The results of this study indicate a low level of content knowledge and moderate levels of preparation for case manager role activities. Nurse case managers require essential knowledge and preparation for case management practice; the transition to a new case manager role cannot rely on experiential learning and requires further professional or formal college education outside the traditional nursing skill set. Many case management courses are available in nursing colleges or university programs in Western developed countries.
Participants were all from Taipei, Taiwan. Other areas of Taiwan have different geographical and educational resources, and knowledge levels may not be generalizable to other regions. Another limitation of this study is the primary focus on PHNs’ perceived knowledge and preparedness levels in relation to case management. This study did not examine actual practice. Finally, the activity instrument used in this study was originally developed in the United States. Although expert panel reviews were used to ensure that the instrument was appropriate to the target population, further studies should explore the case management practices of Taiwanese PHNs to more suitably consider Taiwanese sociocultural considerations.
Relevance to Clinical Practice
Taiwanese PHNs require additional educational preparation to improve professional knowledge and preparedness for case manager role activities and achieve better case management outcomes. According to this study, 82% of PHNs had no prior education in case management. The findings revealed that PHNs scored low on knowledge tests and possessed only moderate preparedness for case manager role activities; this must be addressed in continuing educational programs.
The traditional view holds that experienced nursing staff should have innate case management expertise. However, our study results confirm that learning from experience is not adequate to acquire systematic professional knowledge. This is especially true for formal curricula, which avoid contact with new developments in service modes or methods. Our results indicate substantial gaps in Taiwanese PHNs’ knowledge and preparation for case management practices. Therefore, there is an urgent need to strengthen case management continuing education for PHNs in Taiwan.
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