Acuity and case management: a healthy dose of outcomes, part II.
OBJECTIVE
This is the second of a 3-part series presenting 2 effective applications-acuity and dosage-that describe how the business case for case management (CM) can be made. In Part I, dosage and acuity concepts were explained as client need-severity, CM intervention-intensity, and CM activity-dose prescribed by amount, frequency, duration, and breadth of activities. Part I also featured a specific exemplar, the CM Acuity Tool, and described how to use acuity to identify and score the complexity of a CM case. Appropriate dosage prescription of CM activity was discussed. Part II further explains dosage and presents two acuity instruments, the Acuity Tool and AccuDiff. Details are provided that show how these applications produce opportunities for better communication about CM cases and for more accurate measurement of the right content that genuinely reflects the essentials of CM practice.


METHODS
The information contained in the 3-part series applies to all CM practice settings and contains ideas and recommendations useful to CM generalists, specialists, and supervisors, plus business and outcomes managers. The Acuity Tools Project was developed from frontline CM practice in one large, national telephonic CM company.


METHODS
Dosage: A literature search failed to find research into dosage of a behavioral intervention. The Huber-Hall model was developed and tested in a longitudinal study of CM models in substance abuse treatment and reported in the literature. Acuity: A structured literature search and needs assessment launched the development of the suite of acuity tools. A gap analysis identified that an instrument to assign and measure case acuity specific to CM activities was needed. Clinical experts, quality specialists, and business analysts (n = 7) monitored the development and testing of the tools, acuity concepts, scores, differentials, and their operating principles and evaluated the validity of the Acuity Tools' content related to CM activities. During the pilot phase of development, interrater reliability testing of draft and final tools for evaluator concordance, beta (beta) testing for content accuracy and appropriateness, and representative sample size testing were done. Expert panel reviews occurred at multiple junctures along the development pathway, including the 5 critical points after initial tool draft and both before and after beta-test (n = 5) and pilot-test (n = 28) evaluations. The pilot testing body (n = 33) consisted of a team of case managers (n = 28) along with quality analysts (n = 2), supervisory personnel (n = 2), and the lead product analyst (the developer). Product evaluation included monitoring weekly reports of open cases for the 28 case managers for 3 months (June-August 2000).


RESULTS
The Acuity Tools suite was used to calculate individual case acuity, overall caseload acuity profiles, case length, and acuity differentials. Normal distributions and outliers were analyzed and the results used for internal quality improvement and outcomes monitoring.


CONCLUSIONS
To show value, case managers need to access the evidence base for practice, use tools to capture quantities of intervention intensity, and specify precisely the activities that produce better outcomes. Acuity and dosage can help case managers explore and fully describe their own practice in ways that can be measured. This data-driven evidence contributes to the accumulating body of definitive proof regarding the exceptional worth of CM. Proving business and professional worth in CM though evidence-based practice is a clarion call that case managers must heed and an innovation that all case managers can practice.
College of Nursing, University of Iowa, Iowa City, IA 52242, USA.
Kathy
K
Craig
Diane L
DL
Huber
D019090:Case Management / Q000458:organization & administration*; D003625:Data Collection; D003627:Data Interpretation, Statistical; D003953:Diagnosis-Related Groups / Q000145:classification* / Q000706:statistics & numerical data; D019317:Evidence-Based Medicine; D006801:Humans; D008137:Longitudinal Studies; D017146:Models, Organizational; D020380:Needs Assessment / Q000458:organization & administration*; D015403:Nursing Evaluation Research; D015588:Observer Variation; D017063:Outcome Assessment, Health Care / Q000458:organization & administration*; D010865:Pilot Projects; D019984:Quality Indicators, Health Care / Q000458:organization & administration; D015203:Reproducibility of Results; D012720:Severity of Illness Index; D016526:Workload / Q000145:classification* / Q000706:statistics & numerical data