Managing Continuity of Care Through Case Co-ordination

Key Implications for Decision Makers

This study examined the usefulness of guidelines to community-care case co-ordinators. These are people who co-ordinate healthcare services for elderly clients, still living in the community, who have some limitations in their ability to live independently. The guidelines are specific to a brokerage model, where the co-ordinators do not actually provide services, but the methods can be adapted to suit many models.

  • Guidelines for case co-ordination set standards for how much time co-ordinators spend with elderly clients who require multiple community health services. Guidelines can increase consistency and accountability when managing continuity of care among co-ordinators.
  • Guidelines should be based on actual practice, rather than preferred practice, to ensure realistic timelines.
  • Guidelines should be based on the time co-ordinators must spend on clients and the needs of the clients themselves. These guidelines benefit service delivery, program planning, staff supervision, performance improvement, education, and training.
  • Different guidelines are required for clients, depending on how at-risk they are of being placed in an institution (low, some, or high risk). As risk of institutionalization increases, use of case co-ordination time and homecare services increases, as does the amount of contact with clients, family, and service providers.
  • Clients are most concerned about being assessed quickly. Therefore, guidelines should include parameters on how to classify urgency of assessments.
  • The time allocated to clients of varying risk must be flexible enough to respond to variables that can increase or decrease co-ordination time (for example, support, dementia, poor health).
  • Reassessments should be based on client need rather than arbitrary time frames.
  • Continuity of care can be improved with regular communication between case co-ordinators and service providers.
  • Clients and providers need educational materials to make sure they understand the role of case co-ordinators.
  • There are two main difficulties to implementing guidelines: 1) large caseload sizes, which require a great deal of time; and 2) fear of rigid application, which would supersede co-ordinators' professional judgment.

Executive Summary

Community case co-ordination assists elderly clients requiring community-based healthcare to receive services and reduce or delay the use of acute care and long-term care. Case co-ordination typically involves assessment of client needs, care plan development and implementation, monitoring service provision, and reassessment. Despite the general framework of these activities, perceptions of case co-ordination often differ considerably, particularly in regard to the nature and frequency of co-ordination services. In addition, the amount of co-ordination is not always adequately linked to the client's level of need. The purpose of this project was to develop guidelines for community case co-ordination that were linked directly to the client's level of need. In order to increase the usefulness of the guidelines, the goal was to base these guidelines on actual practice as opposed to preferred practice.

Data were collected on clients receiving community case co-ordinated services. The clients were older than 65, and entered the study at their initial referral to case co-ordination. At that time, their risk of being institutionalized was determined. Case co-ordinators tracked the time they spent co-ordinating services for each client in the study over six months. After examining actual case co-ordination practice as a function of client's level of risk, guidelines were drafted by an expert panel of case co-ordinators, decision makers, and researchers. A series of focus groups including clients, service providers, and decision makers evaluated the guidelines. A brief tracking form based on the draft guidelines was piloted in May and June of 2003 and feedback was used to form the final guidelines.


This study provides objective data for use in better understanding case co-ordination of community health services for elderly, community-dwelling clients. Guidelines can be used to reduce inconsistency in case co-ordination delivery and to improve accountability. As well, the guidelines increase awareness of current practices for those not directly involved in case co-ordination. Decision makers can use this objective data in program planning and to gain a greater understanding of resources needed for case co-ordination. The guidelines can assist with the education and training of new case co-ordinators by establishing benchmarks to guide practice. The guidelines may also be used as a quality measure, to ensure fair and consistent case co-ordination, both on an individual and aggregate level. The specific times and ranges developed will likely vary by region as well as by the case co-ordination model employed (for example, brokerage versus care-based), but the method and format of developing guidelines could be applied to any region or other client populations.


This project resulted in the development of case co-ordination guidelines that specify ranges of co-ordination time and frequency of contact with elderly clients based on the client's risk of being placed in an institution (low, some, high). Data analysis revealed that the majority of new referrals to case co-ordination exhibit low or some risk of institutionalization. However, those clients exhibiting higher risk used more case co-ordination time and more homecare services on average. The data gathered on case co-ordination time revealed that the majority of case co-ordination occurs in the first month for assessment, plan development, and plan implementation activities, and then tapers off into a monitoring function.

Participants in this study said guidelines should have a wide range of case co-ordination times to allow for professional judgement and for individual client variability. Also, case co-ordinators requested lengthening the amount of time between scheduled full reassessments for low-need clients (for example, three years instead of one year), as reassessing low-need clients annually was felt to be inefficient. To ensure clients were appropriately monitored for changes in their health or support status, routine service reviews were built into the guidelines at three months for new clients and one year thereafter. In addition, the guidelines specify that when clients experience significant changes in functioning, service use, or social support, the co-ordinator initiates a service review or a full reassessment to ensure the clients' changed needs are fully understood and appropriately met.

Identified barriers to success and recommendations

Analysis of information collected through focus groups demonstrated that potential barriers to implementation of guidelines included fear of rigid application, a disconnection between co-ordinators and service providers, need for staff buy-in, increased paperwork, and high caseload sizes. To address these concerns, the guidelines were emphasized as a supportive tool with scheduled service reviews to foster greater communication among co-ordinators and service providers. Staff buy-in was achieved through inclusion of staff in the development process, a pilot implementation, and continuous feedback. Paperwork was kept to a minimum through the addition of only one new activity tracking form and one service provider form. High caseload sizes were taken into consideration by tracking only a small portion of clients at any given time. Parameters for how urgently assessments should be done were also added, as clients identified this as an important aspect.

In summary, we recommend that guidelines for case co-ordination are necessary to ensure consistency and quality of service delivery. Guidelines must be based on actual practices and available resources, not preferred arbitrary standards. Guidelines must be flexible to allow for variation within need levels, but not be as wide in range as to be meaningless in setting expectations for service delivery. Development of effective guidelines also requires the involvement of case co-ordinators, clients, service providers, and decision makers. Finally, by gathering information about case co-ordination, a better understanding and appreciation of the nature and importance of case co-ordination is achieved by clients, service providers, and decision makers.