Calgary Singles Acuity Scale Toolkit

Transcription

1 Calgary Singles Acuity Scale Toolkit Prepared by the Calgary Homeless Foundation in partnership with The Alex Community Health Center Background and Introduction Efforts to sustainably end homelessness are underway in communities all across North America. The Calgary Homeless Foundation (CHF) leads Calgary s 10 Year Plan to End Homelessness. This community plan includes several strategies specifically focused on a sustainable end to homelessness. A critical factor in ensuring success includes a coordinated system of care with diverse and varied Housing First programs. System wide coordination of these programs requires evidence-based processes that determine the level and intensity of case management a person needs and matching that person to housing and support programs that are designed specifically to support that level of intensity. Best practices for right matching of services often include the use of an acuity scale designed for case managers to assess the number of issues and the severity of those issues for their clients. Information collected using an acuity scale can also assist supervisors in their overall program management specific to balanced time commitments and caseloads. One such tool is the Denver Acuity Scale. In 2010, service providers operating Housing First programs in Calgary identified a need to develop a tool to assess client acuity and to match that acuity to case management service planning. The tool needed to be relevant to Calgary s local context. To this end, The CHF and The Alex Community Health Centre (the Alex) began engaging in research to support the This toolkit is designed to enable service providers in their use of Calgary s Acuity Scale. Information for this toolkit came from a literature and environmental scan, from review of other acuity scales and from successes and lessons learned from approximately 12 months of use by the Alex. Defining Acuity Acuity is an assessment of the level of complexity of a person s experiences. It is used to determine the appropriate level, intensity and frequency of case managed supports to sustainably end a person s homelessness. Acuity is a measure of systemic issues such as poverty and housing costs, as well individual factors such as: Mental health Substance abuse Domestic violence Medical concerns Age Life skills Employment history/potential Education Social supports

2 Two factors can impact a person s acuity score, the number of individual and systemic issues present, and the severity of those issues. The more of these issues and the higher the severity of the issues the individual is experiencing the higher their acuity. Acuity vs. Vulnerability Understanding a person s vulnerability is often used to determine mortality risk and to use that information to prioritize them specifically for rehousing. Determination of vulnerability is often based on the research of Dr. Jim O Connell (Boston, MA) and Dr. Stephen Hwang (Toronto, ON). Their study from Boston found that the following health conditions increase the mortality risk for homeless people: More than six months street homeless AND at least one of: 1. End stage renal disease 2. History of cold weather injuries 3. Liver disease or cirrhosis 4. HIV+/AIDS 5. Over 60 years old 6. Three or more emergency room visits in prior three months 7. Three or more ER or hospitalizations in prior year 8. Tri-morbid (mentally ill+ abusing substances+ chronic medical problem) Those with a higher incidence of these indicators are considered to be more vulnerable and to have a higher risk of mortality. Survey participants are ranked based on their vulnerability and this ranking provides a criterion for prioritizing individuals for housing. There are distinct differences between acuity and vulnerability. Housing First programs began assessing client needs in Calgary using vulnerability scores. What case managers soon found was the level of vulnerability did not necessarily align with the intensity of supports they knew their clients needed. Instead, tools that measured a high vulnerability in clients often showed up in low acuity clients, as well, clients with low vulnerability scores often showed up in clients with high acuity. Initially we thought we could use the vulnerability score as a way to tell us who needed the most service but quickly realized the two are very different hence the need to develop an acuity scale Calgary case manager Tables 1 and 2 below compare client scores using both vulnerability and acuity tools. They clearly show a wide range of differences between the two, for example, clients with an assessed vulnerability of 3 or 4 (high vulnerability) show acuity scores that can range from 0 to 650.

3 Table 1: Client acuity vs. vulnerability of 3 Table 2: Client acuity vs. vulnerability of 4 Information about the acuity levels of all clients in a program can be used as an internal planning tool for supervisors to manage their staff to client ratios and staff time commitments. Specifically, by monitoring the range and number of clients who would be considered, low, medium and high intensity, supervisors can make informed decisions about: Program fit and right matching of services, ensuring client profiles meet the eligibility criteria for the program design System flow, comparing aggregate information across and amongst service providers to ensure consistency of service across the continuum of care

4 What is the acuity scale? Background/development Calgary s community of Housing First service providers identified a gap in their ability to adequately determine the level of client complexity and the appropriate number of caseloads for individual case managers and for overall program intakes. This led to the need for a tool to support case managers and their supervisors for assessment and planning purposes. In the 1980 s an intensive case management program in Denver, CO, identified a need to develop a model of case management designed specifically to support people with very high needs. Their model included community based visits, 24/7 supports and inclusion of people with lived experience as case manager aides. The high level of need of the program s clients led to the development of a tool to assess and monitor overall case numbers and intensity of case manager s caseloads. The tool is called the Denver Acuity Scale and uses a 5 point scale on a continuum measuring high intensity of need (5) to little or no intensity of need required (1-0). The categories were developed using a panel of experts with experiential knowledge and the tool was then tested using a management information system to determine any clients who were being over or under served. The average length of time needed for each client visit was assessed at 50 minutes, to ensure a balance between provision of onsite supports with time for paperwork, meetings and training. It was determined that case managers should spend 60% of their time with clients and 40% doing other administrative duties. If a case manager in a high intensity program had 20 clients who were simultaneously in the initial phases of the program (scores of 4 and 5), their clients were being under served. Conversely, if a case manager had 10 clients at the 9 month mark all with scores of 1 and 2, this could lead to inefficient use of resources as case managers would be spending less than 60% of their time serving clients. The Denver Acuity scale became an effective assessment of readiness to graduate. Those clients who showed consistent stabilization of low acuity scores over time (approximately 6 months) were deemed ready for graduation. In one study of the effectiveness of the Denver Acuity scale, only 4% of clients over a three year period decompensated, that is, were readmitted to the program or showed higher acuity scores after showing a consistent drop during service. The Calgary Homeless Foundation in partnership with the Alex Community Health Centre developed a process to research best practices, scan existing acuity scales and adapt them for the Canadian context. The CHF was particularly interested in developing a tool that could be used consistently across the homeless serving sector to target those who are chronically or episodically homeless. As well, ensuring the final tool was compatible with the Homeless Management Information System (HMIS), developed to support a coordinated and responsive system of care. The Homeless Management Information System (HMIS) in Calgary is a locally administered, electronic data collection system that stores longitudinal person-level information about persons who access the homeless serving system. It assists the community to gather accurate, real-time data regarding the total number of homeless, length and causes of homelessness, demographic characteristics, and their needs. Of particular importance is the ability of the HMIS to streamline client access to necessary services through a common intake and assessment process. The acuity scale will be built into the HMIS as one of a number of individual electronic assessments available to Housing First programs.

5 The research led to the development of the Calgary Acuity Scale which is currently being tested for effectiveness by staff in the HomeBase program at the Alex Community Health Centre. The tool itself was adapted to an excel format for ease of use and compatibly with HMIS. Initial testing of the tool was done with clients that were well known to case managers. They were able to compare the assessed acuity score to their professional judgment and expertise, particularly with clients they had established a relationship with. Ongoing processes will include inter-rater reliability testing to determine if different team members get the same score when assessing the same client. By the time we reached the final version we felt that it was reflective of the service requirements. There were several versions. We did notice that we needed to sit down as a group and discuss definitions to ensure we were all utilizing the scale the same way. Calgary Case Manager Supervisor What does it measure? The acuity scale is a short assessment done by the case manager at intake, several times throughout the case management relationship and prior to program discharge to assess the level and intensity of services an individual requires, as well as progress and/or setbacks. Specifically, the scale assesses strengths and barriers in the following areas: Economics income and potential to earn income Demographics specifically age Social and Emotional indicators Domestic violence Employability Availability of social networks Life skills Extreme vulnerability Mental health concerns Substance abuse Medical concerns Cognitive abilities

6 Scoring and Assessing Clients Acuity scoring is a tool to support case managers, and should therefore be used as a guideline, professional judgment is still necessary to ensure people are being supported in ways that protect their individual rights and personal choices. Case managed supports should be offered and client choices determine actual supports provided. Acuity is determined through a comprehensive assessment of the above factors, the clients final score is used to design an individualized case management plan. Over time, client scores are expected to improve. While each person is unique in their experiences and their needs, the acuity scale, when used consistently with individuals and across a system of care, can be an objective assessment of need. Case managers assess the level of severity of issues in each section on a scale from 1-5. For example, when assessing income, a score of 5 would indicate no income while a score of 1 would describe someone with adequate income in no need of rent subsidy to maintain housing. An example, including issues that are strong determinants of need, (as named above), is severity of existing medical conditions, that is, if a person needs treatment and medication immediately and is a high user of hospital emergency rooms, they would receive a score of 5. If however, they have no presenting medical issues they would receive a score of 1. Case managers use their professional judgment to assess and score clients by placing an x in the appropriate category. Once all categories are filled in the total score is added up. This score is used to match clients to the level and intensity of case managed supports needed. The higher the overall score, once all areas have been assessed, the higher level of supports a person would need. All indicators are scored from 1-5, however, the extreme vulnerability indicators are weighted more heavily. Economic, demographic and social and emotional indicators will add 1-5 to a person s score, as well if a client scores from 1-4 on the extreme vulnerability factors their score is numbered accordingly, if however they receive a score of 5 on the extreme indicators, their score increases from a 5 to a 200. Potentially increasing their score by 800 should they score a 5 in mental health concerns, substance abuse, medical concerns and cognitive abilities. For example: a client is assessed with a 3 or 4 in economics, demographics and social and emotional indicators, giving them a total score of 35 before the extreme vulnerability indictors are entered. If this client scores a 4 in all four of these indicators their overall acuity score would be 51. Indicating a medium level of intervention needed. If however that client scored a 5 in all four of the extreme vulnerability indicators, their score would increase to 835, indicating a very high acuity and therefore very high level of intervention needed. One question we have is regarding once someone is over 312 does it matter how much higher their score goes? For example we have a few clients who have scores in the 600 s what does that mean? Calgary Case Manager The first assessment is typically done within the first 30 days of the case management relationship. It is important for the case manager to spend some time getting to know the person, as well, meeting with as many other professionals as possible who may be working with their client.

7 We usually try to speak to as many other professionals involved with the client as possible in order to create as full a picture as possible. Some of the categories do require more than preliminary information. Calgary Case Manager Assessing case loads and time commitments The tool itself can also assist supervisors to collect and assess individual case manager and overall program intakes and caseloads. This helps ensure balanced time requirements of case managers and capacity to respond to client needs. Experience using the tool has determined that a high acuity client, or one that requires daily case management interventions, would require at least 7 hours per week. A weekly client would require approximately 3 hours per week. These can be used as guidelines, as additional time may be required to respond to unforeseen issues or immediate crises. Information about case manager caseloads can be tracked easily by calculating the total number of overall clients, then total clients who are high, medium and low acuity for each case manager. This gives individual case managers, the team and the supervisor a quick visual snapshot of caseloads, allowing assessment and then readjustment to ensure equity. This process allows supervisors to be proactive in reducing staff burnout and/or ensuring case managers with high acuity caseloads have the supports they need to effectively manage their time and properly support their clients. We had one CM who ended up with 5 daily clients which essentially takes 35 of the 37.5 hours in a week. A discussion then takes place between the CM, the team leader and the rest of the team to re-distribute the case load. A daily client also tends to indicate a more urgent need to seek more community supports for that client as they tend to require more than we can offer. Reviewing caseloads is an ongoing process. Calgary Case Manager Supervisor Table 3, 4 and 5 below illustrate examples of actual case manager case loads and time requirements as provided by the Alex Community Health Centre.

8 Table 3: Overall caseload distribution by case manager Table 4: Caseload distribution at intake

9 Table 5: Caseload distribution at 6 months When a CM tells us they are feeling overwhelmed and we see that they have more than one daily client it allows us to try and figure out how to better support them. Calgary Case Manager Supervisor Keeping track of overall numbers of clients within each level of acuity also allows supervisors and their staff to determine how many high acuity clients they have overall, and therefore, if the current staff level and/or number of partnering service providers in place are enough. A visual understanding of this, created opportunity for engagement of additional community service providers to share in the necessary supports. Additionally, if a Housing First program was designed specifically to support those who are considered to be episodically homeless and medium acuity, and their acuity assessments show a majority of chronic high acuity clients, a decision needs to be made to potentially re-evaluate the client/program fit. This is particularly important if several assessments over time consistently show this. Matching Acuity Score to Case Management Plan A person s acuity score should reflect their current and short term service needs in each of the areas in the scale. Case managers should incorporate, as much as possible, information from the client that is verifiable or documented in the case file. Certain areas within the scale itself may indicate higher acuity than others. These areas should be prioritized within the case management plan. For example, presence of a severe physical health issue that has not been adequately addressed would take precedence over a person s readiness for employment. If however, a client has a severe or chronic physical health issue that is being adequately supported by health care professionals, they would score lower in this area, this would lower their acuity specifically regarding physical health concerns. A person s assessed acuity score is then used to determine: Frequency of face to face meetings Time required of case manager Level of support required from supervisor

10 A persons acuity score indicates whether they are considered low acuity (score between 14-30) and therefore require low intensity case management. Medium acuity, (score between 31 and 311), therefore require medium intensity case managed supports or finally, high acuity and in need of high intensity case managed supports (score of 312+). Case Examples Case Example 1: Client was a male in his early 40 s He has had several years of homelessness He was recently discharged from federal prison His vulnerability score was low, primary health issue was frostbite Acuity score is 451 High acuity score is due to 2 extreme indicators; Mental health Cognitive dysfunction This client was supported with an intensive case management program to address his physical and emotional health issues. He received daily visits from the primary case manager and had a team of service providers around him to support his needs.

11 Case Example 2: Client is a male in his mid-30 s He has 2 to 3 years total homelessness His vulnerability score is high due primarily to chronic health issues Acuity score at intake was 32 Low acuity is primarily due to presence of adequate supports for his chronic health condition As well, He has none of the extreme indicators and scored well in life skills and external relations This client was assessed as low acuity and therefore received low intensity case management supports. At the 6 month assessment, his acuity had improved to 27, primarily due to adequate ongoing support for his chronic health issues. Case Example 3: Client showed a vulnerability score of 0 At intake acuity was assessed as 639 High acuity was primarily due to scoring highest in 3 of the 4 extreme indicators; Mental health, substance abuse and cognitive dysfunction

12 High intensity case management was introduced, at six months, the acuity score dropped down one level in mental health and cognitive dysfunction. Once the client had received needed supports to deal with the mental health and cognitive issues, this client went from requiring daily support to weekly support. Low Acuity and Low Intensity Case Management Programs (Rapid Rehousing) A Low Intensity Case Management program provides targeted and time limited financial assistance and support services to individuals and families in order to quickly exit emergency shelters and obtain and retain housing. Low Intensity Case Management programs target individuals and families who have the ability to live independently after a time limited subsidy and supportive services. Therefore, primarily people considered to be transitionally homeless should be their focus. Rapid Rehousing programs are common to this program category. Since continued low income and high housing costs may persist after rehousing occurs, low intensity case management programs include systems navigation and linking with appropriate mainstream services, low intensity case management intervention is time-limited usually up to 1 year. A score in the low acuity range (14-30) indicates the need for minimum monthly face-to-face meetings with client and case manager. Also, if a case manager works primarily with low acuity clients, caseloads should not exceed 1:25. Medium Acuity and Medium Intensity Case Management Medium intensity programs provide housing and intensive supportive services in a more structured approach than low intensity programs. Services and housing are time limited and designed to facilitate movement to independent living or permanent housing. The length of stay in these programs typically does not exceed 18 months. The target client group for this program has often experienced long term homelessness (chronic) or many episodes of homelessness in their lifetime (episodic). They also experience difficulty exiting homelessness on their own due to a major barrier (mental health, addiction, domestic violence, etc.), in addition to financial and housing cost barriers. These support programs are designed to help client s access employment services, substance abuse and mental health treatment. If clients are properly assessed and matched to medium intensity programs at entry, clients success in these programs should be high. Appropriate service planning is important for medium intensity clients and must account for the various risk factors an individual experiences. These often simultaneously include mental health, addictions, abuse, and low income. Case management can support the long term stabilization of this group. These programs focus on enhancing protective factors to prevent future homelessness. These may include enhancing clients employment, education, social connections, parenting skills, mental and physical health supports, as well as housing and neighborhood quality. Medium Acuity scores range from A person with a score of would require minimum bi-weekly face to face meetings. A person with a score of would require minimum weekly face to face meetings. As well, case manager who primarily work with medium intensity clients should have caseloads that do not exceed 1:15/20.

13 High Intensity Case Management High Intensity Case Management programs are long-term housing for homeless individuals who also have a major disabling condition. Often clients in high intensity case management programs have more than one complex issue (e.g. serious mental or physical disabilities, chronic addictions, lack of employability), in addition to financial and housing cost barriers. These programs primarily support those who are chronically homeless. The intent of these programs is to provide intensive case management supports for complex needs, long-term, often up to 24 months of service. Extensions of support may be required, depending on the client`s needs and this is assessed on a case-by-case basis. These programs can be delivered by an individual case manager working with a client, or through a team based model (e.g. Assertive Case Management model). In Calgary, such programs are able to assist clients in market and non-market housing through wrap-around services and financial supports to subsidize rent and living costs. These programs ultimately work to support clients towards increased independence, and therefore, services are focused on sustaining stable housing. Due to the high acuity and complexity of client needs, some may require a permanent supportive housing program more appropriate for ongoing supports without a maximum length of stay. High acuity scores would be those 312 and above. A score this high indicates extremely high needs and a minimum of daily face to face visits between case managers and/or team and the client. Case managers who work primarily with high acuity clients should have caseloads that do not exceed 1:10. They will require ongoing support from supervisor s to ensure they are able to balance client needs and client case loads. Through ongoing assessments using the acuity scale that show improvements over time, clients may move from high intensity to medium intensity programs or from medium intensity to low intensity programs. As well, in some cases, client acuity may increase, necessitating a move from lower intensity to higher intensity programs. Assessing Acuity over Time An important component of doing assessments throughout the case management relationship is to assess progress and, prior to discharge, readiness to leave the program. A steady drop in acuity scores shows clients are reaching their set goals and moving towards increased self-reliance and independence. Assessments can be done at intake, and then every six month following, but can be done as often as every 90 days and 30 prior to discharge. Assessing an appropriate time for discharging or graduating clients is an iterative process. That is, case managers must balance an improvement in acuity scores over several assessments (minimum 3) with their and their supervisor s professional understandings of readiness to discharge. For example: if a client starts the case management relationship with a score of 54 at first assessment, showed a score of 44 after six months, a score of 34 at 12 months and 24 at 18 months, a case manager

14 could begin the process of preparing clients for graduation, as long as an assessment at least 30 days prior to discharge shows sustained or continued improvement. There may be several options that arise after months of case management and acuity assessments: A client may be ready to formally leave the case management relationship A client may be referred to a less intensive program that better meets their needs, A client may need long-term intensive supports and therefore referral to long term care Consistent use of the Calgary Acuity Scale and adding appropriate levels of case managed supports to match client acuity is showing success over time. Table 6 below shows the average acuity scores for all clients over a 12 month period from initial assessment, 6 month assessment and 12 month assessment. Table 6: Decline in Assessed acuity scores overtime We do see scores go down and that does tend to indicate a client is getting ready for graduation. For me the most useful aspect to date is the confirmation it provides regarding the acuity of clients and how it allows us to review caseloads. The questions it raises are very helpful. Calgary Case Manager Supervisor

15 Lessons Learned Staff training and support It is very important to spend time with staff talking about how to use the scale and ensuring that everyone is using it the same way including consistent definitions. Some of our CM s were worried that it was a label for clients and we discussed that is it only a case management tool and not a way to label someone this reduced their reluctance to score some items at the higher end. Calgary Case Manager Supervisor Partnerships are key The Calgary Acuity Scale is most accurate and useful when it includes information collected from collateral resources Consistent use The Scale is only useful as an internal organizational tool for case planning if you review and discuss the scores on an ongoing basis. Internal Use The scale is typically not used with clients but by case managers for their own information. However, there is no reason why clients could not see and/or know about the tool and why case managers are using it. We don t really use this with clients. We have selected other tools to use to help them evaluate their own situations and develop their own goals etc. The acuity scale is good info for CM s to (use) as they support their client. Although we have included the acuity scale in our client workbooks as a compliment to the info we use with and for clients. Calgary Case Manager Scale should be reviewed and adapted When using the tool, supervisors should build in a process to review its effectiveness including: overall client numbers and matching acuity to caseloads, assessment of improvement or de-compensation of clients over time housing retention

16 Appendix A Denver Acuity Scale