Adoption of an algorithm and client pathway for the aged and disabled: training implications for the health and human service sectors.

Hewitt, Anne M. ; Polansky, Patricia A. ; Day, Nancy 等

INTRODUCTION

The Administration on Aging (AOA) and the Centers for Medicare and Medicaid (CMS) launched a multi-year grant initiative promoting Aging and Disability Resource Centers (ADRC) to serve as trusted resources for all Americans who need long-term support, especially older adults and individuals with disabilities aged 18 and older (ADRC, 2008). The New Jersey Department of Health and Seniors Services (NJDHSS) subsequently developed and implemented its own state-wide model--The Aging and Disability Resource Connection (NJ DHSS, 2008) which highlighted a "No Wrong Door" approach to service delivery and supported the department's values of dignity, choice and independence.

This report describes the use of a state-sponsored Training Academy as an organizational framework for the dissemination of an algorithm and client pathway to public and non-government organizations and health and human services personnel. The authors review development strategies and implementation challenges of this multi-year, state-wide initiative. Results from ADRC stakeholders suggest the Training Academy strategy was well received.

BACKGROUND

New Jersey, home to 1.5 million residents over the age of 60, has sought to be at the forefront of meeting the demand for sustainable home and community-based care and services (HCBS) for senior populations (NJ DHSS & DACS, 2005). Beginning in the late 1990s, the state's Department of Health and Senior Services (DHHS) began to streamline service delivery and increase consumer friendliness through the New Jersey Easy Access, Single Entry (NJ EASE) project (Reinhard & Fahey, 2003). This first step in the effort to simplify the HCBS delivery process focused on access to services. Anecdotal reports of waiting lists in some counties and none in others had suggested a disparity in service access. NJ EASE was an initial state-wide effort to implement easy access for seniors who needed services via a state-wide toll-free phone number. However, county implementation of NJ EASE was hampered by technical as well as organizational implementation challenges. In addition, the initiative only addressed senior services while policy changes were being recommended at the national level to increase support services for the disabled population (Kennedy & Balbach-Tuleuh, 2007). The NJ DHSS recognized a need to streamline duplicate efforts for both groups and link HCBS for both aging and disabled populations.

In 2003, the New Jersey Division of Aging and Community Services (DACS) was awarded an Aging and Disability Resource Center (ADRC) grant which permitted the agency to redesign access to the aging and disability long term care (LTC) support delivery systems. This initiative supported the establishment of a single pathway for individuals age 18 and over to access services over their lifespan. However, the new initiative involved substantial changes to the previously established state service delivery infrastructure and reimbursement protocols, occurred within a very narrow timeframe, and required training to be delivered to both public health and non-profit partner human service agencies. The division also addressed several essential strategic questions: (a) How to identify the internal and external stakeholders with the potential to influence ADRC outcomes? (b) How to engage and train the various external stakeholders? (c) How to manage the twenty-one (21) county Agencies on Aging personnel and other internal state agencies? (d) How to establish DACS as the primary facilitator of LTC reform in the state? These questions may appear similar to challenges faced by many state agencies when implementing a federal mandate to provide services in a proscribed manner. From a management perspective, it was clear the initiative required DACS to assume the leadership and training roles for both the state and local agencies. Success and sustainability of the ADRC initiative would be tied to ownership of the ADRC project across the state (Hewitt, Field & Polansky, 2008).

The planning phase occurred during the first grant year with over 40 meetings held and 200 state stakeholders participating. DACS responded initially to the implementation challenge by focusing on state infrastructure and developing a workplan that highlighted both leadership and communication strategies. Primary implementation strategies included the following:

1. Designing a Stakeholder Map of ADRC participants

2. Appointing an Executive Management Team functioning across state divisions of disability, health and senior services and Medicaid/Medicare

3. Creating an ADRC county Readiness Self-Assessment Tool

4. Offering a continuous series of county information sessions

5. Participating regularly in Area on Aging leadership meetings

6. Presenting the ADRC initiative to County Boards of Chosen Freeholders

7. Recruiting consultant(s) to serve as facilitators when appropriate

8. Developing a state-wide Training Academy

Once this ADRC infrastructure was in place, DACS reviewed the 14 separate core activities of the agency that formed the HCBS process. This process led to the development of the ADRC model which included both an algorithm and the accompanying client pathway and became the mechanism for change in a statewide health and human services organization.

DEVELOPING THE ADRC ALGORITHM

In a healthcare delivery context, an algorithm is viewed as a strategy that leads to decision making and may involve a decision tree, flowchart or actual decision grid (Healthcare and Workforce Improvement, 2008). Previous algorithm research had documented positive findings on feasibility (Plisza et al., 2003), development protocols (Hornbrook et al., 2007), decision making opportunities (Renella & Fanconi, 2006), integration into state agency protocols and processes (Sullivan, Antle, van Zyl, & Faul, 2009) and validation of outcomes (Seikaly, Loleh, Rosenblum, & Browne, 2004). For the ADRC initiative, the algorithm emerged as a framework that pared down an operation to its most elemental processes and incorporated decision points that would be evaluated for effectiveness.

The DACS leadership team's algorithm development steps involved a range of activities including background research, preliminary mission and vision discussions via think tank sessions with national experts, and several comprehensive executive leadership and statewide hands-on meetings. Each of these activities included the input and collaboration of local, county and state participants from non-profit and public agencies. The logistics of coordinating meetings, selecting and including appropriate health service champions as well as documenting the feedback from front-line and outreach personnel required a concentrated effort and presented major challenges to agency personnel. Multiple iterations of the envisioned service delivery framework were debated and refined by an executive team and division staff. The final version reflected more than a year's work of input and critical reflection. Figure 1 presents the ADRC algorithm and each corresponding phase activities.

[FIGURE 1 OMITTED]

The ADRC algorithm is a succinct framework for the process of delivering support services to both the aging and disabled population. Phase 1 serves as the initial access and client interaction point and is followed by information gathering and introduction to a menu of services in Phase 2. In Phase 3, the partnership between client and counselor establishes eligibility and service options. During Phase 4, consumers direct choice of authorized services and delivery arrangements and in Phase 5 both monitoring and assessment mechanisms are integrated into the process. The algorithm was initially piloted in two counties and preliminary results focusing on the appropriate level of care were validated by an independent, university consultant. Once the algorithm was refined and accepted as the conceptual framework, the next significant challenge was to create the corresponding ADRC client pathway.

DEVELOPING THE ADRC CLIENT PATHWAY

The term clinical pathway usually refers to patient care management tools (Healthcare & Workforce Improvements, 2008) and critical pathways are often thought of as project activities that are labeled as critical because they must be accomplished before an entire project can be completed on schedule. The critical pathway concept has recently been adopted and adapted by the health care industry (Dy et al., 2005). However, a client pathway combines the clinical and critical service delivery steps, but with the overarching goal of designing each activity to benefit the consumer in ease, accessibility and effectiveness. Research has long established the benefits of providing pathways of care, resulting in improvements in patient outcomes, consistency of care, teamwork among caregivers and increased client involvement in care (Johnson, S., 1997). In-depth analyses of medical applications of client pathways have shown that basic algorithms can be expanded to create multiple client pathway options within distinct stages. For example, algorithms that guide telephonic supervision of patients in home environments have included specific pathways that address psycho-educational issues, environmental concerns and medication adjustments. Because algorithms do not inherently impart judgment (Johnson, G., 2007) the ADRC model needed a corresponding mechanism to highlight client interaction decision points within each service delivery step.

Development of the ADRC Client Pathway also followed a participatory process that involved intra, inter-and extra agency collaboration. Workgroups were established and staffed by internal agency personnel as well as inter-agency members from the New Jersey Division of Medical Assistance and Health Services (Medicaid) and the Division of Disability Services, and various external community stakeholder groups such as the County Agencies on Aging (NJ DACS, 2003). Figure 2 presents the ADRC Client Pathway and outlines primary activities from the human service provider perspective.

The ADRC client pathway enhances the ADRC algorithm by outlining the corresponding human service provider activities and perspective. To ensure appropriate client access in Phase 1, the provider role is listening and data gathering. Phase 2 is divided into two sections; Identify One covers screening and the initial assessment counseling for appropriate clients, while Identify Two establishes the protocols for in-depth assessments involving financial, clinical and interdisciplinary team (IDT) roles. Phase 3 Indicate focuses on the facilitator/client interaction step of counseling for the development of an appropriate service plan and Phase 4 follows up this step with arrangement of services through care management. Phase 5 Inquire parallels the algorithm concept and also provides appropriate performance indicators to document successful ADRC outcomes. Together the algorithm and client pathway function as a service delivery template and a teaching and dissemination tool thus creating the foundation for the DACS Training Academy.

[FIGURE 2 OMITTED]

THE TRAINING ACADEMY

The DACS Training Academy was formerly established two years after the ADRC initiative began with two key state staff assigned to facilitate operations. First, the Training Academy framed its value statements followed by a set of goal statements. These statements were then transformed into operational strategies. Table 1 presents the Training Academy values, goals and operating strategies.

With the Training Academy's purpose fully established, the next step was to facilitate the adoption of the three major components of the ADRC model: the algorithm, client pathway and their supporting processes and products. The new ADRC supporting products and processes included a/an: (a) clinical screening tool, (b) revised eligibility screening process, (c) interim eligibility option for home and community based services (HCBS), (d) hospital-based screening for nursing home placement and (e) statewide client tracking system. These tools had been developed with stakeholder input after the algorithm and client pathway had been fully delineated.

ADRC Training Process/Product Implementation

The first three processes to be disseminated and adopted were solutions to the screening, assessment and eligibility roadblocks that had challenged the aging and disability systems over the years. The newly validated

screening tool (NJ Choice) identified five levels of service categories for all state and federal long-term care support services. The recently designed eligibility screening process (NJ Eligibility Screening Process) streamlined the steps for appropriate placement based on level of service need, consumer direction, availability of resources and the ability to ensure health and safety. The interim nursing home eligibility option for HBCS (Fast Track Eligibility Determination Process) focused on consumers who were clinically eligible for nursing home care and met Medicaid financial criteria, but now could receive home and community-based services for a limited number of days while they completed the full Medicaid eligibility applications. Another service delivery activity allowed hospital staff to screen, authorize and place individuals seeking Medicaid admission into a nursing home or on a Medicaid waiver (the Hospital Pre-Admission Screening pilot). The final product, which may eventually surpass the other examples in utility, was the deployment of an integrated client-tracking system (Social Assistance Management Systems) which facilitated financial reporting and client tracking systems as well as provided state-wide data for quality improvement activities (NJ DACS, 2008). Each of these processes represented a significant change in the daily activity of county and state personnel as well as community partner agencies. Figure 3 shows the relationship of the new ADRC processes to the client pathway.

[FIGURE 3 OMITTED]

Training Academy staff was guided by responses from the ADRC county Readiness Self-Assessment tool in developing their training approach. State staff adhered to the traditional teaching phases of introduction, demonstration, guided practice, trial phase-in, and full adoption. Both the algorithm and the client pathway served as the foundation for the series of training sessions implemented across the state during the multi-year initiative. Training academy instructors anecdotally reported that the key to the transformation was the linking of the five innovative processes with the algorithm and client pathway. Case studies of unnamed individual clients were used to apply the algorithm and client pathway processes. The visual cues provided by these tools were constant touch points for the personnel and allowed them to conceptually place a new ADRC process into the appropriate context and view the change process as a concrete activity related to their job responsibilities. The ultimate outcome was the dissemination and integration of the five new products and services into each county's standard operating procedures.

DISCUSSION

The integration of both an algorithm and client pathway as tools for a state-wide training initiative enabled a state Training Academy to disseminate complex changes in process and products within a three year timeframe. Follow-up training surveys indicated participants recognized the utility of the algorithm as a conceptual representation, but responded positively to the step-by-step activities outlined in the client pathway.

Previous state initiatives had failed to be implemented by all counties and had resulted in a continuance of a fragmented service delivery system for two major stakeholders--the aged and disabled (Reinhard & Fahey, 2003). Similar challenges were evident for this initiative, but DACS was able to overcome coordination issues between partner organizations, limited practice management processes and unfamiliarity with consumer directed care by focusing on their core work-plan strategies. In addition, the initial leadership and champion role led to greater trust and networking relationships among all stakeholders. Statewide personnel were able to focus on the service delivery commonalities between the aged and disabled populations.

A funding comparison between the 1997 and the 2007 NJ Department of Health and Senior Services LTC Funding Allocations (State Share) show Home and Community Based funding increasing from 7.3% to 23% of the total allocation (Polansky, 2008). This positive 15% increase in Home and Community Based funding supports the ADRC initiative's goal of meeting the aging and disabled population needs by providing appropriate services that allow for consumer direction and still manage to lower the cost of providing state long-term-care services.

ADRC Initiative Limitations and Challenges

Despite the Training Academy successes in outreach and the adoption of both the algorithm and the client pathway, the primary challenge remained agency software integration and the purchase of information technology software. Although initial compatibility issues were overcome, county funding priorities and state deficit issues limited the adoption of the full multi-million dollar management information system that could provide complete client-tracking system reports. These economic constraints impacted fifty percent of the counties.

Given the funding limitations of the ADRC state initiative, a complete assessment of the Training Academy's approach was not feasible. Pre- and post-satisfaction surveys were collected and analyzed for all training sessions and indicated very positive satisfaction with the training. Other studies have reported on completing archival review of meeting minutes, consumer focus groups, and systematic evaluation of the training to fully document ways to overcome integration challenges (Sullivan, Entle, van Zyl, & Faul, 2009). Additional investigation is needed to assess the importance of using both an algorithm and client pathway as training tools as well as comparisons across agencies and types of personnel. Further research could also focus on the success of implementing a skill-mix approach (Mackenzie, 2006) and the supporting role of interagency collaboration (Vogel, Ransom, Wai, & Luisi, 2007; Hewitt, Field & Polansky, 2008).

TRAINING IMPLICATIONS

Three major training implications can be derived from this report for agencies responsible for implementing federally sponsored initiatives involving health and human service personnel. First, of primary importance, is the development and validation of the algorithm and client pathway by all stakeholders through a transparent process. Repeated revisions of the algorithm and client pathway demonstrated to the trainees/stakeholders that their feedback on all processes and protocols were taken seriously and that the final goal of achieving a workable system was paramount. The benefits of the algorithm were many, including the capacity to (1) provide a visual cue for facilitating teaching and application, (2) serve as a succinct flow diagram to aid in delivery of services, (3) outline the standard operations that need to be completed for each ADRC interaction, and (4) facilitate easy comprehension for front-line outreach personnel.

Second, the sequencing of activities offered by the Training Academy consistently followed the three interactive stages of engagement, empowerment, and assessment. Although the primary purpose of the Training Academy was educational, this approach ensured a logical training sequence for each of the five unique processes and products that were essential to the ADRC model. Repeated opportunities for training and re-training sessions proved invaluable in establishing credibility and stakeholder participation.

Finally, strict adherence to policy guidelines and directives established a best-practice methodology for the training. Trainees, administration and other stakeholders benefitted from having a codified set of regulations that were embedded in the five new processes and products. Gaps in understanding or interpretation were addressed immediately through clarification of protocol or policy statements. This step ensured adherence to state policy and limited the variation that often occurs among counties due to local agency interpretation and established a statewide baseline for services.

CONCLUSIONS

This report describes a concerted effort by a state Training Academy to design and improve on the aging network's ability to meet the needs of both the aging and disabled populations by integrating a state-wide ADRC model. The new ADRC model emerged as the implementation strategy for the initiative because it satisfied key criteria: (a) alignment of the 14 separate core activities under three key functions of awareness & information, assistance, and access (ADRC Fact Sheet, 2008; US DHSS, 2005); (b) fulfillment of the federal requirement to integrate state and local health and human service activities for both the aging and disabled populations; and (c) linkage of HCBS delivery processes with a care management component. The algorithm and client pathway were instrumental tools for the Training Academy in effectively implementing a major service statewide service delivery initiative across 21 counties within a short timeframe. The ultimate outcome was a redirection and increased funding for Home and Community Based services for two vulnerable populations and the implementation of a sustainable service delivery model across the state.

ACKNOWLEDGEMENTS

This project was funded by the Agency on Aging and the Centers for Medicare and Medicaid to the New Jersey Department of Health and Senior Services.

The authors would like to thank the anonymous peer reviewers whose comments were so helpful in the revision of this manuscript.

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ANNE M. HEWITT

Seton Hall University, South Orange

PATRICIA A. POLANSKY

NANCY DAY

NANCY FIELD

ALICE MOORE

New Jersey Department of Health and Senior Services

Table 1
Training Academy Values, Goals and Strategies

Values                         Goals                  Strategies

Quality -            * Providing quality         * The worth of
Developing a         training programs and       its mission is
well-informed,       workshops to every level    demonstrated
professional         of DAC's staff in the       through a well-
network serving      areas of technology,        defined budget and a
the elderly and      human relations,            sharing of personnel
disabled in New      supervision, leadership,    to conduct training
Jersey.              communication and           sessions
                     professional enrichment.
Education -                                      * Individuals
Providing quality    * Offering trainings and    and agencies
training that        workshops to                throughout the State
promotes personal    professionals working in    come together to
choice, cultural     the aging and disability    learn about service
preference,          network in order to         opportunities to
independence and     update their knowledge      support the elderly
dignity that is      and skills.                 and disabled in
adopted by staff                                 communities.
and demonstrated     * Partnering and
by daily             collaborating with other    * Training
operations           agencies that serve the     sessions are diverse
                     elderly and disabled        and held at
Responsiveness -                                 accessible locations
Providing            * Selecting proficient,     to overcome barriers
professionals with   dynamic trainers who        to participation.
the opportunity to   effectively share their
keep pace with the   knowledge and skills        * Training and
ever-changing                                    workshop topics are
needs of the                                     developed in
elderly and                                      response to surveys
disabled and the                                 and evaluations
changes in                                       received from
program/service                                  supervisors, staff
requirements.                                    members, and
                                                 workshop
Inclusion -                                      participants.
Partnering with a
wide array of
stakeholders to
assist in the
development and
maintenance of
quality programs.