Transforming Care Management - W4A · Transforming Care Management ... Caregiving involves an...
Transcript of Transforming Care Management - W4A · Transforming Care Management ... Caregiving involves an...
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TransformingCare Management
An Evidence-based approach for supporting Family Caregivers
Rhonda J.V. Montgomery, Ph.D.Helen Bader Professor in Applied Gerontology
University of Wisconsin- Milwaukee
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Goals for Morning1. Overview of the larger UWM project and its current partners
2. Overview of Caregiver Identity Change Theory as the basis for evidence-based practice.
3. Implications for Service Delivery
4. Introduction to the Uniform Caregiver Assessment and REferral(UCARE) process.
5. Future directions and opportunities for Washington Partners.
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Part I: Overview of Research and Development Activities
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Research Team
Rhonda J.V. Montgomery (UWM)Karl Kosloski (UNO)Mary Brintnall-Peterson (UW-Extension)Vicki Schmall, (Aging Concerns – Oregon)Jeannine Rowe (UWM)Dale Adler (Gerontology Programs
Consultant)& Team of hard-working graduate students
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Practice Partners
State and local agencies in• Florida• Georgia
• Michigan• Washington• Wisconsin
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• Family Caregiver Assessment Tool• Evidenced-based Care Management
protocol• Coordinated training curriculums for
• Family caregivers &• Care managers / Family Specialists
Transforming Care management
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WHY?• Family Caregivers are
– Key partners in long term care– Key to quality elder care
• Programs that are looking for guidance:– National Family Caregiver Support Program (AoA)– Aging Network Services– ADRC (SPE)– Medicaid waiver programs – Chapter Network of Alzheimer’s Association
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Our Vision
• Care managers and family caregivers will determine needs through
– an assessment processand
– match appropriate community services to meet the identified needs.
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How?Target services effectively
• Identify caregivers’ needs
• Understand goals for intervention
• Match services with goals
• At the correct time(when caregivers can & will use service)
• Increase compliance
Analogy to medicine
• Right diagnosis (identify the needs)
• Goal- Cure or symptom?
• The right medicine(correct service)
– The right dosage(sufficient quantity)
• At the right time(prevention not cure)
• Increase Compliance (take the medicine)
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Common Stress Model as Rationale for Support
Burden
CareExhaustion
Abuse
Placement
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Rationale for Support
Burden
CareExhaustion
Abuse
Placement
Support
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Goal of our Work
• Maximize impact of support services for family caregivers– Serve More Clients– Provide better support
• Minimize costs
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Must assess the client “family”• The client is the family
– Caregiver– Care recipient– Family Care context
• Current practice:– Look at care recipient as only client– View family as “visitor or servant”
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Measures of Need Intention to Place
ADL/IADL .14
Problem behaviors -.07
Care ReceiversCare Receivers’’ Needs DonNeeds Don’’t t Predict Intention to PlacePredict Intention to Place
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Caregiving Activities Don’t Predict Intention To Place
Hours in past week spent doing :
Intention to Place
Personal Care -.11
Housework -.16
Transportation .01
Banking/Legal Matters -.02
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Need for Guiding Model
• Understand Source of Distress• Helps identify characteristics that are
appropriate to measure• Points to strategies for intervention
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Diversity Among Caregivers Affects Journey
• Relationship• Gender • Culture• Caregiving Environment
– Functional level of care recipient– Living arrangement– Formal Supports– Informal Supports
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Diversity in Experience
• Comfort level with role • Relationship between CG & CR • Overload or interference with life • Anxiety or stress• Depression• Positive feelings
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1. Caregiving involves an identity change process .
2. Change often involves a lag time when there is a misfit between what a caregiver is doing and what the caregiver thinks she/he should be doing. Lag causes stress.
3. To fully support families we must use strategies to identify this source of stress and remove the “discrepancy” with appropriate interventions .
Pathways Through Caregiving: the Caregiver Identity Model
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Basic Premises About Caregiving Journey
1. There is no single, generic caregiver role
Caregiving role emerges from -prior role relationships
Role influenced by the –unique values, beliefs and circumstances
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Spouse/Partner
Emotional
Banking
Decision Making
Errands / Shop
House Tasks
Emotional
Banking
Decision Making
Errands / Shop
House Tasks
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Spouse/Partner as Caregiver
Emotional
Banking
Decision Making
Errands / Shop
House Tasks
Personal Care
Emotional
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Child
Emotional Emotional
Banking
Decision Making
Errands / Shop
House Tasks
Personal Care
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Adult-Child as Caregiver
Emotional
Banking
Decision Making
Errands / Shop
House Tasks
Personal Care
Emotional
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2. Caregiving is a dynamic process that unfolds over time.
3. The length of career varies
Basic Premises about Caregiving Journey
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Caregiving Journey: Child
010203040506070
0 1 2 3 4 5
Years
HOURS
Bank Shop/Trans Household Other Tasks Personal
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Comparing Journey
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0 1 2 3 4 5 6 7YEARS
HOURS
Bank Shop/Trans Household Other Tasks Personal
010203040506070
0 1 2 3 4 5 6 7
YEARS
HOURS
CHILD
SPOUSE
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The Caregiving Journey Is a Systematic Change Process
• Change in activities• Change in relationship with care
receiver• Change in role and identity of caregiver
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Landscape for Caregiver’s Journey
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Identity in Phase I
CA F
CaregiverCaregiver
SpouseSpouse
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Identity Phase II
F A Spouse
Caregiver
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Identity Phase III
F A
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Identity Phase IV
F A
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Identity Phase V
Spouse
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F A
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Pathways through the Caregiver Journey
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Diversity of Relationships affects the “rules for being a caregiver”
• Who becomes caregiver• How they perform
– What they do– How they do it
• How the feel about it– Burdens– Uplifts
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Basic Premise 4:About Caregiving Journey
The general social & cultural rules governing family relationships create consistencies in the caregiving process.
- But -Unique experiences, family histories and cultural adaptations of rules create unique adaptations to this caregiving process.
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Community
Family
Circles of influenceSociety
Functional level Living arrangementFormal SupportsInformal Supports
Caregiving Environment
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Rules for Behavior(Identity Standards)
We know how to act because we follow our internalized rules.
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Rules for being a Wife
Rules for being a Caregiver
Rules for ME
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Rules for being a Wife
Rules for being a Caregiver
Rules for ME
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Finding balance
Identity Rules
Behavior
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Caregivers experience distress when –
their appraisal tells them that there incongruence between
behavior & personal identity rules.
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Finding balance:Change with “Big CHANGE ” or “small change”
Behavior
what (how) I am doingIdentity Rules
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Big C?
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B C D E F A
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Caregiver
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Maintenance of Identity within a phase.
F A Spouse
Caregiver
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Role Identity(in relation to care receiver)
Identity Standard
BehaviorSelf
Appraisal
?
Identity Maintenance Process
Identity Rules
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Identity Rules
BehaviorSelf
Appraisal
Disturbance of theIdentity Maintenance Process
Caregiving Environment
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change as a adjustment (change with a small “c”).
F A Spouse
Caregiver
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Identity Rules
Disturbance of theIdentity Maintenance Process
BehaviorSelf
Appraisal
Caregiving Environment
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Rethinking Support Services
Part III
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Rethinking Support Services
• Identify the goals for intervention
• Identify most effective strategies
• Ask: Which services are consistent with strategies and will help meet these goals?
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Implications for Selecting ServicesSet the Goal for intervention1. Maintain Identity
2. Increase Caregiver identity
3. Reduce Caregiver Identity
4. Reduce Depression(the Symptom)
Pick Strategies
1. Change Rules
2. Change behavior
3. Change Appraisal
4. Change the Reaction(reduce the symptom)
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.
Intervention StrategiesIdentity Rules
Strategy A: Change or adjust rules
1. Education about:
• Disease Process
• Caregiving Journey
• Loss and Grief
• Understanding Difficult behaviors
2. Counseling
3. Support Groups
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Intervention StrategiesIdentity Rules
1. Make less difficult
• Teach CG Skills
• Teach CR Skills
• Assistive technologies
2. Introduce alternate sources
• Adult Day care
• In-home services
• Informal Help
3. Alternate Care Setting
• Assisted living
• Nursing Homes
Strategy B: Reduce Workload
Behavior
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Intervention StrategiesIdentity Rules
BehaviorSelf Appraisal
Strategy C: Encourage positive appraisal
1. Counseling
• caregiver journey
• family relationships & communication
• Resolving guilt feelings
2. Education
• caregiver journey
• cognitive reframing
3. Support groups
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Intervention StrategiesIdentity Rules
BehaviorSelf Appraisal
Strategy A: Change or adjust rules
Strategy B: Reduce Workload
Strategy C: Encourage positive appraisal
Strategy D: Reduce Generalized Stress
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Strategy D: Reduce Generalized Stress
1. Make less difficultTeach CG SkillsTeach CR SkillsAssistive technologies
2. Introduce alternate sourcesAdult Day careIn-home servicesInformal Help
3. Alternate Care SettingAssisted livingNursing Homes
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Support Strategies
• A: Change Rules
• B: Reduce Workload
• C. Support positive Appraisal………………………
• D: Reduce stress
• Identity Standard
• Behavior
• Change Appraisal
…………………….• Reduce symptom
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Typical Tool Box for Intervention
• Education Programs– Information– Skills– Emotional/ Psycho-educational
• Support Groups• Counseling• Respite• Case Management
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Targeting Interventions• What to target
– Identity Discrepancy?– Objective Burden– Relationship Burden– Stress Burden
• What do we change?– Behavior– Self- Appraisal – Rules
• Choice of Support Service– Education– Support Group– Counseling– Adult Day Care– In-home Support– Assistive Technologies– Informal Helpers
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Education Programs• Information to help change Rules
– Disease Process – Caregiver journey/ identity change – Understanding loss an grief
• Education to reduce stress– Cognitive reframing– Coping skills– Stress management
• Teach or improve care skills – Direct care skills– Responding to difficult behaviors
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• Change source of appraisal (new sources)• Help re-interpret appraisal
– Of other care receiver – Of other family members
• Teach about sources of help (to lower task demands)• Help change the Identity Standard
– (incorporate caregiver tasks into current identity)• Reinforce transitions
– (Give permission to change identities or reject role)
Support Groups
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Counseling
• Changes identity standards• Re-interpret appraisals• Facilitates shift to New Identity
– (new standards)
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Respite: Positive
• Reduces work load – Substitute for caregiver– Change context
• Helps merge care role into primary identity (e.g. wife, daughter)
• Reduces Objective Burden
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Respite: Negative When
• Negative appraisal from respite workers
• Negative appraisal from kin
• Creates work
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Part III: UCARE
Uniform Caregiver Assessment & Referral
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CARE MANAGEMENT USER MANUAL
• Evidence-based process that is:– Grounded in the Caregiver Identity Theory– Reflects current knowledge of research about caregiver
interventions.
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Characteristics of Good Assessment
1. Captures the full range of differences among family caregivers
2. Is sensitive to change
3. Easy to use
4. Understandable – to client & to care manager (transparent)
5. Instructive – Care manager knows how to use the information to guide practice
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UCARE- an Assessment Process• Core Assumption: Matching services to needs leads to:
– Correct service at the correct time– Compliance with suggested care plan– Greater potential for positive impact
• Assumes transparency & Client Choice
• Provide insights about caregiver’s context– Identifies strengths & challenges– Types and Sources of Burden/Stress– Appropriate Goals– Strategies (not services) – Options
• A wide array of services are useful and available to support Caregivers
• Not all communities have all services.
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How to implement the UCARE process?
Four steps for working with family caregivers
Step 1: Assessment of Caregiver Needs
Step 2: Interpretation of information to determine type and level of need
Step 3: Identify goals, support strategies and services
Step 4: Family consultation to develop a care plan
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1. Caregiver Screening Tool
2. Caregiver Assessment Form
3. Assessment Summary Sheet
4. Service Selection Maps (five maps)
5. Guide for Selecting Support Services
6. Care Plan Form
Tools for Implementation
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Benefits of UCARE• Uniform Assessment
– Guarantees equal opportunity for caregivers to obtain help– Not dependent on individual care mangers’ knowledge
• Informs Intervention & Care Plans– Focus on prevention – not crisis– Focus on strategies not services
• Provides Guidance for Planning– Helps identify service gaps– Helps identify new resources– Guides allocation of resources
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League of Experienced Family Caregivers
(LEFC)
Seeking the Wisdom of Family Caregivers
www.familycaregivers.uwm.edu
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Domains to be Measured• Caregiver Status:
– Length of Caregiving– Phase of Caregiving– Intention to Place
• Caregiver’s Obligations– Hours of Care– Number of Other Dependents– Employment Status
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Domains (continued)• Caregivers Emotional &
Physical Status– 3 measures of stress and burden– Identity discrepancy measures– Depression– Caregiver Health– Caregiver Uplifts
• Caregiver Resources– Informal supports– Income
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Domains (continued)
• Care receiver Status – Functional level (ADL/IADL)– Problem Behaviors– Diagnosis– Memory problems
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Version 2. 0Brief, 8 pages, 32 Questions
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For Example
52
42
53
3
3
43
43
34
43
4
52
2
33
21 2018 15
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Scale Score
Easy to Interpret
• Transfer information to AssessmentSummary Sheet to interpret score
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Transfer Scores
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Transfer Scores
2118
2015
Interpret Score to
Determine Need
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Guide for Choosing Service Selection Map
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Service Selection Map A
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Guide for Selecting Support Guide for Selecting Support ServicesServices
Rhonda J. V. Montgomery, Ph.D.
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Guide HeadingGuide Heading
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NEXT STEPS
• Using and Testing Full UCARE Process• Grant Applications
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Seeking Partner Organizations
– Commitment at all levels of organization– 4 to 6 care managers – Commitment to training 2 to 3 care mangers
• 2-day intensive• 1 follow-up• Technical assistance consultations
– Use with 3 to 4 caregivers– Share assessments & care plans for one year
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Rhonda J.V. Montgomery, Ph.D.
Helen Bader School of Social WelfareP.O. Box 786University of Wisconsin - MilwaukeeMilwaukee, WI [email protected]