The Women’s Health Network Case Management Evaluation Project

1. The Women’s Health NetworkCase Management Evaluation Project Russell Schutt, Ph.D. Harvard Medical School & UMass Boston with Elizabeth R. Cruz Jacqueline Fawcett, Ph.D., Brooke Harrow, Ph.D., Tony Roman, MS and Gail Gall, with assistance of Maria Rocha-Tracy University of Massachusetts Boston

2. Project Goals • Describe client experience. • Describe case manager experience. • Identify influences on case management. • Describe perceptions of case management. • Identify influences on service outcomes.

3. Criteria for Case Management • All women with abnormal screening or diagnostic test referred for CM • All contracted agencies required to contract with licensed health care provider to deliver CM services.

4. Research Methods • Interviews with DPH contract managers (N=3); • Interviews with WHN case managers and program coordinators (N=31 sites); • Analysis of service use data (N=3178); • Phone survey of random sample of WHN service recipients (N=207). • Qualitative case manager data.

5. Client Survey Methods • Population = Case Managed Clients • Stratified Random Sample, N=207. • 177 with problematic cancer test result • Response Rate of 73% • 24% could not be found • CVD-only treatment cases not sampled • 20-minute Phone Interviews • Measures: • Program Experience • Program Assessment • Overall Health • Demographics

6. Outline • Overview of Clients • Client Evaluation of WHN Services • Case Manager Evaluation of WHN • Case Management Work • Evaluation of Case Management Work • Overview of Case Managers Conclusions

7. Client Overview

8. Health Problem of CM Clients 31 Case Managers; 3178 Service Clients

9. Overall Health, Care Status Phone Survey of 207 Clients

10. Client Social Characteristics (Problematic test only) Clients with problematic cancer test are younger, more English-speaking, and more often white. Phone Survey of 207 Clients

11. Client Evaluation of WHN Services

12. Testing CM Helped With Phone Survey of 207 Clients

13. WHN Services • Average of one year since last test—either breast or cervical. • Average of 10 months since last time WHN Case Manager helped.

14. Satisfaction With Services Phone Survey of 207 Clients

15. Client Rating: Case Management • CM Help Rated Higher Than Overall Help on 10-point Scale • 84% of Problem Test Clients Helped “a lot”; • 65% of Other Clients Helped “a lot.” Phone Survey of 207 Clients

16. Barriers to Services, Problematic Test Result N= 177 phone survey respondents with problematic test result

17. Cost Issues N= 177 phone survey respondents with problem test

18. Language Problems

19. Barriers by Language Phone Survey, 148 English primary; 28 others.

20. % Cervical Cases by % Hispanic Service Data, WHN Sites

21. CM Satisfaction by Education Phone Survey, 148 English primary; 28 others.

22. Service Problems & Depression Phone Survey, N=207.

23. Case Manager Evaluation of WHN

24. Issue is a Moderate or Major Problem for ClientsCase Manager Rating

25. Problems for Client Service • Fear of medical bills rated as moderate or major problem by >80% CMs. • English fluency, scheduling by 60%. • Maintaining contact, underestimating risk, health beliefs, limited service knowledge by 40-50%.

26. Barriers of Cost & Insurance • “It takes a lot to get the patients to understand that this is a free service. And they are probably thinking that I’ve been told this before. …But people have been burned at other places where they’ve been told things were free and they weren’t – a trust issue.” • “Sometimes they need to have services that are not covered by us. …doctors order things and they are not covered and sometimes they don’t have the free care to pay for it. And then the treatment is very fearful. …So you really have to help them to get reduced fees, to get the care that they need.” • “We tell them what rights they have… Some people feel ashamed to be here without insurance.

27. Treatment Cost Problems • financial counseling. Much much much much much much less [needed] since the Treatment Act was passed. But it’s still there. …a client diagnosed with breast cancer. Treatment program eligible, but she wasn’t gonna be able to work. …living hand to mouth as it was and her question was what if I can’t pay my rent. So where will I live and how will I eat were the questions that came up with the last 2 who were diagnosed.”

28. Case Manager Comments: Client Barriers of Time & Health Views • “Fluency in English – oh good Lord that’s a major problem. And the only thing that helps us is the interpreter.” • “Time is a major problem between work schedules, kids’ school schedules, husbands or significant others’ schedules. And the regular business hours of the mammography center is 9 to 5, Monday through Friday – no Saturdays, no evenings.” • “very afraid to lose their jobs…but I only have one clinic day.” • “it is important to make sure that somebody is following them because they don’t oftentimes view the follow-up Pap smear or that follow-up mammogram as being important. And if we weren’t pushing them to do it, I don’t think they would.”

29. The Work of Case Managers

30. Mean WHN Clients, Past Month

31. Case Manager Work Summary • Average of 3.3 WHN work roles. • Average of 20 hours in WHN roles. • Average of 10 hours as case manager. • Most interact frequently with coordinator & client navigator. • All report some training; almost all would like more training.

32. Case Manager Comments on Client Service Problems • “The biggest challenge is that I don’t have the time to actually specifically manage each and every one of them – it’s a time issue.” • “The challenges are the documentation and the restrictive nature of the definition of case management.” • “Financial restrictions of the grant are problematic. I’d like to be able to do a lot more for people - to do more with nutrition, more with exercise. And it’s just not available, it’s just not there.”

33. Case Manager Work Load • Over half find workload heavy. • Workload rated heavier if more case management hours in particular. • Workload rated heavier in CVD sites

34. Case Manager Comment about the Multiple Work Roles • “There are many different avenues to go to. …my program coordinator is full of knowledge and …then I can go to other case managers if I have a question….” • “because our program is hospital based it is easy for me to coordinate, and plan services with our providers”

35. Case Manager Comments about Adequate Work Processes • “The staff here is very well aware of the confidentiality of clients. And I don’t think it’s a problem but there are a lot of staff that work here and live in this area. And a lot of our clients are from this area. So you need to treat someone that you see here, even if you’re a friend, like they are supposed to as a patient.” • I think we have a great awareness of culture here. We’re so diversified with the different cultures that we and our employees are very aware of it.

36. Case Manager Comments about Work Activities • “Lots of time I’m following-up to get people rescheduled. And for some reason some patients seem to take several attempts. Other patients even though they are supposed to call me with the date for their diagnostic forget and I need to call them and find out when they are scheduled. Sometimes I have to call them afterwards too. Some patients just keep you informed – boom, boom, boom. And others – I don’t know.” • “Finding, connecting with clients – I need to follow-up with them and I can’t find them. I would say that probably happens with a good 50% of our clients. They change phone numbers, changed address – out of the country. I’d say that happens every week.

37. Evaluation of Activities • Rated “Very Well” by 60-70%: service planning, learning needs, assessing needs, tracking tests. • Rated “Very Well” by <50%: finding clients, arranging discharge, monitoring progress. • Rated “Very Well” by <50%: training, evaluating services.

38. Case Manager Comment about Evaluation of Activities • “Follow-up, getting in touch with patients… I’ll call them, I’ll send out letters, and then I’ll send out registered letters. And if I haven’t had any response within a month then I just take them out. They are basically lost-to-follow-up. And sometimes they’ll come back to the program and then ding I’ll nab them.”

39. Least Adequate CM Processes • Computer support. • Policy manual. • Client education material. • Timely test results. • Staff education material.

40. Summary of Work Reactions • In spite of much change and multiple roles: • Most feel responsibilities complementary. • All are very or somewhat satisfied with job. • Almost all find the job very or somewhat like the job they wanted.

41. Case Manager Comments about WHN Strengths • “… these patients have someone to connect with, to rely on, and to feel as though they’re not alone – they have less to worry about maybe.” • “… it makes you more attune to keeping track of patients. So these are people that I really follow closely to make sure things are done.” • “The client contact – women who have been really hesitant and due to being pursued quite a bit they did go get care. And most of the time it turns out to be nothing. But once in a while it has turned out to something women need to take care of.”

42. Case Manager Overview

43. Case Manager Characteristics

44. Case Manager Training

45. Conclusions about Clients • Most enter due to breast cancer test. • Clients report more CM pap test help. • Clients very satisfied with WHN & CMs. • Barriers due to $ concerns • #1 for both clients and CMs • More cost info needed, $ for 20% billed • Language major problem for CMs • Cervical tests lower for Hispanics. • Cultural issues. • Satisfaction higher for more educated. • More problems for depressed—but CMs DK.

46. Conclusions about Case Managers • Case managers very satisfied with work. • Multiple roles for most and heavy loads. • Need for more training, IT support. • Tracking clients is a problem. • Service networks lessen problems. • Hospitals • Translators • Reduce paperwork burden.