Caseload management is defined as ‘an organisational technique that involves individuals and families healthcare needs being met by the appropriate person at the appropriate time’ (Bain and Baguley, 2012). Caseload management involves caseload analysis, care coordination, scheduling care, delegation, prioritisation, workforce planning, leadership and teamwork (Roberson, 2016). This paper highlights particular challenges arising in caseload management in the Irish context and describes the implementation of a national project focused on standardising caseload management in the Republic of Ireland (ROI).
Role of the public health nurse in the ROI
In Ireland, the role of the public health nurse (PHN) is outlined in Circular 41/2000 as follows: ‘The public health nurse will focus “on a district or area meeting the curative and preventative nursing needs for the population within the area”’. The Public Health Nurse will be expected to provide a broad based integrated prevention, education and health promotion service and to act as co-ordinator in the delivery of a range of services in the community’(Department of Health and Children (DOHC), 2000).
The PHN provides care across the life span, including the delivery of a universal core screening and surveillance service to all children born in the ROI. PHNs face a daily challenge managing and delivering care to adults, children and people with disabilities. In addition, they play an important role in assessment and ongoing review for social support services to enable older people to remain at home. There is continuous pressure on the PHN service to facilitate early hospital discharge and increasing demand to provide ever more complex nursing interventions. Caseload management in this environment is, therefore, extremely challenging. In essence, the PHN role encompasses the role of the district nurse, school nurse and health visitor in the UK.
The Health Service Capacity Review (Department of Health (DOH), 2018) was commissioned in response to increasing pressures in the health services and was an indication of the Government's desire to plan for future healthcare services in Ireland. This report recommended fundamental reform of health services and significant investment in both acute and primary care services. The review projected a 46% rise in the demand for public health nursing appointments and a 70% rise in the demand for home support services by 2031. Critically, the report forecasted the need for an increase of 67% in PHN grades. In 2016, there were 1500 PHNs in post, and, by 2031, it is forecasted that a total of 2600 PHN posts will be required to meet the increased need in line with population growth and health needs. The nursing division of the DOH has recently prioritised a taskforce to examine workload measures in community nursing.
There are indications at government policy level that this model of PHN service delivery may soon be transformed. ‘First 5’, a government policy published in 2018, has recommended the development of a dedicated child health workforce (Government of Ireland, 2018a). The implementation plan published in May 2019 contains detailed steps to progressing this action (Government of Ireland, 2019a).
Caseload management
As a caseload manager, the PHN is accountable for ensuring the quality, effectiveness, efficiency and co-ordination of care. For caseload management to be effective, the nurse, at the very minimum, requires accurate data on referrals, activity and caseload size and, most importantly, acuity and dependency.
However, there is no national system in use within the public health nursing service to measure workload or patient acuity. Reports as far back as 2004 identified a need to measure the work of the PHN (Begley et al, 2004). Yet, there remains a dearth of evidence within the literature relating to caseload management in public health nursing, and the evidence generally draws on that of the district nursing services in the NHS. Evidence gathered from existing public health nursing areas in the ROI indicated variations in referral procedures and the absence of written criteria (Pye, 2011), which has led to variations in caseload size and subsequent allocation of resources.
The points of entry and exit to the public health nursing service are fundamental to caseload management. One mechanism through which caseload management can take place is through the development and application of clear referral criteria to the service. Service objectives need to be clearly stated to target nursing resources to areas of greatest need (Botting, 2003). In contrast with the UK, this is particularly problematic in the Irish public health nursing service due to the two-tiered nature of the health services, where only 31% of the population is eligible for care to be provided free at the point of delivery (Government of Ireland, 2018b). As a result of this ambiguity, eligibility criteria for the public health nursing service are unevenly applied while those charged with the implementation of Slaintecare—the new healthcare strategy for Ireland—are attempting to clarify and address eligibility and access issues more generally to Irish healthcare services (DOH, 2017). Thus, this issue continues to create many challenges for public health nursing in Ireland.
Current political context
The Future of Healthcare Report/SlainteCare (DOH, 2017) outlines a 10-year plan to transform health and social care services in the ROI. The detailed implementation plan that followed in 2019 lists key actions in relation to preventative health, access to universal healthcare, provision of care closer to home and an integrated system of care (Government of Ireland, 2019b). Fundamental to the success of Slaintecare will be the creation of a health system where care is provided on the basis of need rather than ability to pay. In Ireland, there are virtually no universal entitlements to healthcare. The 1970 Health Act only sets out eligibility for some services. People with full eligibility (medical cards) have access to a range of health and social care services free of charge. This eligibility issue has implications for service delivery by allied health and social care professionals, PHNs in particular.
Caseload challenges
In addition to eligibility to access the public health nursing service, good discharge processes are also needed and can facilitate the active management of the PHN caseload, including caseload profiling (Kane, 2008; Pye, 2011). Historically, PHNs were reluctant to discharge patients, and this impacted on their ability to safely manage caseloads. This issue has also been reported in the NHS district nursing service, where caseloads have been referred to as ‘sponges’ that absorb additional workload in an environment without the physical limits of a desired number of beds (Queen's Nursing Institute (QNI), 2016). In Ireland, PHN caseloads have no agreed upper limits, and there have been reports of individual PHNs carrying caseloads of up to 500 patients, due principally to the fact that PHN caseloads are based on population size (Pye, 2011). According to Hanafin et al (2002), there is a need to move towards a more population health needs approach. The December 2018 metric figures show that 2.5% of the population in the ROI is in receipt of public health nursing clinical services.
Thus, it is clear that a mechanism through which caseloads can be managed in an objective, fair and transparent way is essential.
Background to project
The Nursing and Midwifery Board of Ireland (NMBI) provides guiding principles to all nurses on responsibility, accountability and autonomy in relation to patient care. These outline expectations in meeting the standards of care of the profession that include sound professional judgement, nursing actions and omissions of care (NMBI, 2014; 2015). In the absence of clear guidance and national support on discharging of patients, PHNs were exposed professionally, caseloads were overly large, and responsibility and accountability for caseloads were, therefore, compromised. Some attempts were made to deal with these issues in 2003, when a detailed research study was carried out to test the Community Client Need Classification System (Begley et al, 2004). This system was piloted in the west of Ireland but did not progress to full implementation. Another approach was considered in 2015 when the Primary Care Division (Health Service Executive (HSE) division operationally responsible for PHNs) introduced a set of national activity metrics for all primary care clinical staff (HSE, 2014). The objective of these metrics was to capture national data on caseload admissions, discharges and waiting lists. At the time of introduction, a National Primary Care Management System was in development that would also have supported data collection. This system was subsequently reviewed in the context of other information and communication technology (ICT) developments and has now been overtaken by the development of an electronic health record (EHR) for use by all health and social care professionals (DOH, 2013).
Frontline staff face challenges arising from lack of ICT infrastructure, a limited induction period and metrics that did not reflect PHN clinical activity or support caseload management processes. Return of national PHN activity data ceased 7 months after commencement. As a result, there was no national return of PHN clinical activity, including reportable key performance indicators. Local paper-based activity returns continued using non-standardised templates with no agreed activity definitions.
In recent years, there has been significant investment in ICT hardware for primary care. The majority of PHNs now have access to ICT. However, there is no software system to support public health nursing services with caseload management. Manual caseload registers are in use in most areas, and a few areas are using locally designed MS Excel-based patient registers. Thus, there was a clear need for a caseload management framework for public health nursing services in the ROI.
Approach adopted/methodology
The approach adopted for the development and implementation of a caseload management framework for public health nursing in the ROI was underpinned by the Model for Improvement change management tool (Institute for Healthcare Improvement (IHI), 2019).
Model for Improvement
The change management tool selected to implement this project was the Model for Improvement. This is a simple but powerful tool for accelerating improvements. The model entails following seven logical steps (IHI, 2019), described below for this project.
1. Forming the team
In 2016, a national partnership group of PHN management, frontline staff and representatives of staff organisations formed a sub-group to address the need for a standardised approach to caseload management, which included the collection of national activity metrics. This group was chaired by the National Lead for Public Health Nursing and was under the governance of the HSE National Primary Care Metrics Technical Group, with support provided by the National Nursing Office. The national project team comprised a national project officer, national practice development co-coordinator and national lead for PHN service.
2. Setting the aims
The aim of the sub-group was to develop:
3. Establishing the measures
Box 1 outlines the metrics finally agreed for implementation, and Box 2 lists the suite of metrics collected for different care groups and age groups.
4. Selecting the changes
This project commenced in September 2016. Draft activity metrics and definitions were devised, and an extensive consultation process took place. This involved workshops with all grades of PHN staff and circulation of a feedback form. The workshops generated much debate, but the priority for frontline staff was the need for metrics to reflect both direct and indirect clinical nursing activities.
Providing cross-cover for other PHN colleagues is a consistent feature of public health nursing caseload management. Colleagues provide cross-cover for child and family services for all planned leave. This has an impact on general caseload management and reduces time available for low-priority clinical work. Staff organisations stressed the importance of capturing and measuring this cross-cover activity.
As there was no software management system available for data collection, other options had to be explored. Following discussion, it was agreed that MS Excel worksheets with embedded formula to capture the activity data and calculate the caseload admissions, discharges and caseload size would be used. Three worksheets were designed to capture data at PHN, geographical network and Director of Public Health Nursing (DPHN) levels. To support the use of these worksheets, each DPHN was advised to apply to a local ICT department for a ‘shared folder’. This is a secure system that allowed for collection of data locally and automatic merging of data at network and director levels. A manual collection sheet was designed for the few areas with limited network access (mainly the offshore islands).
In PHN areas where there were no ‘shared folders’ in place, management and/or administration staff were required to copy and paste PHN data into the DPHN management sheets. Following an application for support to the National ICT Department, technical support has recently been approved to establish a national shared folders system for public health nursing services.
5. Testing the changes
The activity metrics were tested for a 4-month period prior to formal commencement of data collection (September 2017 to December 2017). The testing followed a plan, do, study, act (PDSA) cycle, which helps test a change in real settings. This is a scientific method for action-oriented learning (NHS Improvement, 2018). The testing revealed that staff required significant support with the technical aspects of data collection. Some changes were made to improve the design of the MS Excel sheets, with prompts included to improve data entry.
6. Implementing changes
Implementation of the national metrics was underpinned by a formal memorandum of understanding (MOU) between the HSE and the main nursing staff organisation. This MOU contained the agreed steps to implementation, a requirement for evaluation and a commitment by the HSE to provide sufficient ICT support to public health nursing services to facilitate data collection.
Regional workshops were held by the national team to prepare identified ‘champions’ in each area. These champions then provided small, group-training sessions locally and dealt with any queries. The use of such champions in change management projects is well reported. There is considerable evidence from multiple disciplines pointing to the importance of champions for moving new innovations through the phases of initiation, development and implementation (Shaw, 2012).
In mid-2018, an extensive evaluation process was carried out (6 months after full implementation) that involved administration of questionnaires to all PHNs and administrative staff. Regional workshops were also held. Feedback identified the need for further clarity to metric definitions. There were no changes recommended to the data set or second version of metrics (2019 sheets).
7. Spreading the changes
The data collection system is now fully embedded into practice. By April 2018, a 100% return rate was recorded (Table 1). The common terminology of caseload management has now become the language that public health nursing staff use when discussing caseloads. The caseload management framework is also included in the curriculum of the postgraduate diploma in public health nursing courses across three higher institutes of education.
| Public health nursing clinical activity metric | Activity in 2018 | Comment |
|---|---|---|
| Total number of referrals received | 146 916 | All referrals received undergo preliminary screening as per the ‘Management of referrals accepted to the public health nursing caseload’ procedure (draft document, expected publication in January 2020, at www.hse.ie/phn) |
| Total number of referrals not accepted | 12 903 | 8.78% of the referrals received were not accepted to the caseload due lack of identified nursing need/refusal of service by the patient |
| Total number of referrals accepted to the caseload | 134 013 | All newly accepted patients to the caseload have to be seen with 12 weeks of acceptance to caseload |
| Total number of discharges | 105 786 | National discharge criteria in place supported by the national procedure ‘Discharge of a patient from the public health nursing caseload’ (HSE, 2019a) |
| Total caseload size (across ages and care groups) | 118 691 | The average caseload size was 93 (this excludes the Child and Family caseload) |
| Face-to-face contact activity in the home | 1 006 000 | - |
| Face-to-face contact activity in the clinic/primary care centre | 361 116 | - |
| Face-to-face contact activity in other settings | 35 100 | - |
| Total face-to-face contacts | 1 402 216 | - |
| Indirect activities | 625 000 | This is a count of the number of indirect activities over 15 minutes in duration |
| Waiting list KPI: Percentage of new patients accepted onto the nursing caseload and seen within 12 weeks | 100% | The national KPI target for 2018 was 96%. The actual target reached was 100% |
KPI: key performance indicator
Metrics of child and family health activity for public health nursing services were excluded from this project. Staff are now seeking a similar collection system to capture these data. Consultation on this project is due to commence with all public health nursing staff in quarter 4 of 2019.
The change process is now complete, and a dedicated public health nursing page has been created on the HSE website to share resources (https://www.hse.ie/phn).
Policies to support caseload management
In 2017, the HSE launched a standardised template for the development of regional and national policies, procedures, protocols and guidelines (HSE, 2016). In addition to providing the details of each procedure, the template covers the evidence underpinning the procedure, governance and approval arrangements, an implementation and communication plan and audit compliance tool. Two key procedures were identified to support the new processes associated with the caseload management framework: (1) management of a patient accepted to the public health nursing caseload (draft document, expected publication in 2020, at www.hse.ie/phn); and (2) discharge of a patient from a public health nursing caseload (HSE, 2019a).
Discussion
This project is the first step in the development of a comprehensive national caseload management framework for public health nursing services in the ROI. It provides a clear system for screening and acceptance of referrals, prioritisation, caseload stratification and discharge. It also provides a profile of clinical activity in home, clinical and other settings and a count of indirect nursing activities. The next priority for the national project team is the formulation of a system or activity metric that will provide a measure of work undone—the so-called ‘missed care’ (Phelan and McCarthy, 2016). In the absence of a software tool or caseload management system, the collection of these data is likely to prove difficult, as the information on which to base the metric has to be extracted manually from paper-based caseload registers. An MS Excel-based caseload register is being tested, which should enable easy extraction of these data; this resource will be available in 2020.
Anecdotally, it is accepted that lower priority work, for example, existing patient reviews, is given less weightage than newly referred patients and those recently discharged from acute services. The national waiting list metric for public health nursing, which measures ‘new patients accepted to the caseload and seen within 12 weeks', was 100% in 2018. By and large, this target is being met even now, but at the expense of lower priority work within the caseload. Consultation on the best system to gather data on missed care is commencing in quarter 4 of 2019.
A national system is urgently needed to capture acuity and dependency, which can inform strategic workforce planning and a move towards a population health needs approach. With increased emphasis on population-based planning and care in the community from Slaintecare, it is crucial that such a system is devised and implemented. There is a serious risk that, without this, any increased nursing resources will fail to target areas of greatest need. In the UK, several commercial caseload management tools are available, but there is little published evidence of their reliability and validity (National Quality Board (NQB), 2018). The NQB (2018) recommends that a common classification system for patient acuity, dependency, frailty and complexity be agreed for district nursing, and that future development of tools should take this into account. It also recommends development of metrics to evaluate workload to allow national district nursing services to be benchmarked and improvement opportunities to be identified, as there is no nationally mandated data collection system in place. Since nationally mandated metrics have now been implemented in the ROI, the logical next steps must be the development of a nationally agreed acuity, dependency or frailty system. The planned project by the nursing division of the DOH on workforce planning is an important step and will add a further layer of knowledge regarding community nursing caseloads.
Expanding community nursing services must be viewed within the context of existing workload demands. Strong evidence must be presented to support the case for additional nursing resources as well as emphasising the ongoing professional pressures that public health nursing services are experiencing. A recent example of this is the national policy decision to deliver the human papilloma virus vaccine programme to boys in secondary schools (HSE, 2019b). Workforce planning business cases developed by public health nursing management used data from the activity metrics to support the need for additional resources to support implementation of this new programme. As further new programmes and initiatives are launched for use within community nursing, it is critical that public health nursing management is in a position to demonstrate existing workloads with reliable evidence of waiting list data for both existing and new patients.
Financial and resource-related pressures in the wider health service have the potential to impact on the delivery of public health nursing services. For example, as a result of an overspend in the health service budget in 2019, the approval of home support hours for older persons was severely curtailed. The result of this is likely to be an increase in home visits to older persons by PHNs as they strive to support maximum dependent patients and cope with increasing clinical risks. The value of standardised monthly activity returns cannot be overstated. This practice allows for benchmarking of nursing activity and performance across the 26 counties in the ROI and may indirectly reflect the impact of wider policy changes. For activity metrics to be deemed valid and reliable, they must measure what they were intended to measure and produce the same results when different individuals carry out the measurement (Health Information and Quality Authority (HIQA), 2012; 2013). For this reason alone, clear, well-defined definitions for each of the activity metrics was identified as crucial for accurate benchmarking. According to HIQA, service providers should minimise inconsistencies and variations in service provision (HIQA, 2012; 2016).
The volume of cross-cover (counted in minutes) provided by PHNs (to cover colleagues' leave) is now returned monthly. This is then converted into a whole-time equivalent (WTE) figure, which can be costed and used to support business cases for filling of vacant caseloads. Table 1 outlines the volume of face-to-face clinical activity in the home and clinical settings in 2018. Interestingly, 70% of face-to-face activity occurred in the home setting. Tracking of home versus clinical activity over time may reflect levels of acuity/dependency within caseloads. Indirect nursing interventions constituted 31% of overall nursing activity in 2018 (Table 1). The 2004 study by Begley found that nurses spent 25% of their time on indirect care. While not comparable figures, there is a commonality in the findings (Begley et al, 2004).
The project described was a substantial change management intervention that involved approximately 2000 community nursing and administration staff across the 26 counties. The Model for Improvement approach to implementation proved to be a useful and concrete methodology (IHI, 2019). The step-wise method appealed to the implementation team and provided assurance to frontline staff. Public health nursing management played a key role in providing leadership from the outset, ensuring governance and high quality of the activity data and embedding the discharge and referral procedures into practice. The project continues to be supported nationally, and the activity metrics can be amended annually to respond to new measures and key performance indicators (KPIs). For example, in 2019, a new KPI was developed to capture the percentage of patients with lower leg wounds who were referred onwards for assessment.
Although the NHS organisational structure is significantly different from that of the Irish health system, there is an opportunity to apply the learning from this project to the UK district nursing service. There are many similarities between the clinical role of the PHN and the role of the district nurse. Unlike Ireland, there has been considerable investment within individual NHS trusts into software systems for community nursing. (NQB, 2018) Organisations such as the Queen's Nursing Institute and the Royal College of Nursing (RCN) are well positioned to advocate for the development of a standardised data collection system for use by district nursing teams. The need for such a system in the UK was one of the key recommendations of a recent QNI and RCN report (2019).
Conclusion
The successful implementation of a national caseload management framework in the ROI has increased the visibility and profile of public health nursing services across the country and has assisted PHNs in caseload management. The activity data are now reported in the HSE performance management reports, and targets for public health nursing services are set annually in the HSE Service Plan. At a strategic and corporate level, data are available for service planning and resource allocation. Validation of data and regular training sessions to ensure data reliability are ongoing.
The greatest challenge facing this project was the absence of software systems to support caseload management and the collection and return of activity data. The introduction of the EHR into the wider health service will be welcomed by healthcare staff, although it needs to have the capacity and flexibility to meet the requirements of community nursing. The projected increase in the community nursing workforce anticipated by the findings and recommendations of Slaintecare and the bed capacity review (DOH, 2017; 2018) must be based on a tool founded in evidence and allow for strategic expansion of the workforce in line with a population health needs approach.
The planned pilot of a dedicated child health workforce outlined in ‘First 5’ is the first step in the separation of the PHN service into a clinical nursing and child and family service (Government of Ireland, 2018a). Determination of the child health workforce required to meet current and projected need must be underpinned by a solid evidence-based rationale. Phase 2 of this project, which involves agreement on child health activity metrics and the associated definitions, will provide a foundation for caseload size and caseload acuity in advance of full implementation of a dedicated child health workforce.