The document discusses the development and implementation of a process to track and measure social work outcomes in a community-based case management program. It provides background on the program and describes existing measures of outcomes related to healthcare utilization, costs, and clinical quality. The authors note that these existing measures do not fully capture social workers' contributions. To address this, they developed a tool to document the unique impacts of social workers across 16 issue categories like housing, nutrition, and education. The tool outlines potential outcomes for each issue and allows tracking of whether outcomes were achieved or reasons for non-achievement.

1. Social Work-related Outcomes in
Community Based Case
Management
Maria Champagne, MSW, APSW
Carlos Estrada, MSW, APSW

2. Objectives
• Appreciate the social work profession’s need
to more specifically identify our impact on
health outcomes.
• Discuss the development and implementation
of a process to identify, track and measure a
variety of social work-related outcomes in
community based case management.
• Analyze social work-related outcomes in
community based case management.

3. Presentation Overview
• Background and significance
• Community Based Case Management (CBCM)
program description
• CBCM program outcomes
• Social Work Case Manager (SWCM) outcome
tool development
• SWCM outcomes
• Next steps

4. Burden of proof
With the emergence of Accountable Care
Organizations and Medical Home models,
Social workers are well-equipped to
provide case management to vulnerable
populations by “helping them transition
among different levels of care, stabilize
their social environments and adhere to
their care plans.” (Collins, 2011) But how
do we prove it?

5. . . . In these times of health care reform
and cost containment, it becomes
imperative that social workers
demonstrate the usefulness and
effectiveness of their role within
interdisciplinary teams. . .

6. Social work departments in health care
settings have often lacked reliable
mechanisms for tracking outcomes thereby
rendering social work’s contribution and
efforts invisible to administrators
(Auerbach, Mason, & Heft LaPorte, 2007).
Problem . . .

7. We developed an outcomes tracking
instrument specific to our program, clients
and community, in order that we might:
In order to address this problem…
1. Document the unique contributions made by Social
Workers within our department.
2. Allow us to engage in research about our practice
to determine what works most effectively.
3. Better incorporate evidenced based practice
models as well as contribute toward this body of
knowledge.

8. But first, who we are…
Aurora’s Community Based
Case Management Program

9. Aurora Health Care, Inc.
Largest health care delivery system
in Eastern Wisconsin
• Private, Not-for-Profit integrated health care
provider
• 31 counties, 90 communities
• 15 hospitals
• 170+ Medical & Behavioral Health Clinics
• Home, Residential, and Inpatient Hospice
• Home Care & Durable Medical Equipment
• 70+ Pharmacies
• 30,000 caregivers, including 1500+ employed
physicians

10. Community Based
Case Management Program (CBCM)
• Began in 1997 in the Greater Milwaukee
Area
• Case management of defined populations*
with chronic medical illness and high
utilization
• *Defined populations currently consist of
persons with Aurora employee insurance,
Medicare, Medicaid, Select Commercial
insurance, and uninsured

11. Target Population
Primary criteria:
•Defined ins. population
•Adult (>18 yrs)
•Primarily use Aurora facilities
•Utilization concerns (i.e. 2 or
more ER or Inpatient visits in
the past 12 months)
•Chronic medical illness(es)
(i.e. Diabetes, CHF, COPD,
Cancer, Chronic pain)
Additional considerations:
•Lack of awareness of community
resources
•Medical diagnosis with downward
trajectory
•Multiple providers involved with care
•Need for care coordination
•Over/Under utilization of physician
office/clinic
•Perceived inability to mobilize supports
•Potential for frequent utilization
•Sub-optimal self-management

12. Program details
• Voluntary; free to patients
• Team Case Management Model oftentimes
used
• 8 Advanced Practice Nurses; 2 Advanced
Practice Social workers (Social Work added to
program in 2002 at Nurses’ request)
• Community-based setting (home, physician
office visits and/or community agency visits)

13. How do Case Managers get involved?
• Patients referred by inpatient, clinic and/or community
health care providers for chronic illness and utilization
concerns
-- or –
• Patients identified through review of utilization
data/reports related to chronic illness
• NCM offers program to patient and then enrolls client
into program; NCM may ask for SWCM partner at the
start or as case unfolds, depending on the prevalence &
complexity of psychosocial / financial needs

14. Program Statistics:
(Averages over the past 5 years)
• # of referrals/year - 350
• # of new patients enrolled/year - 80
• Total # of patients active/year - 125
• % of cases with SWCM involvement - 45%
• Caseload for NCM - 10 – 15
• Caseload for SWCM - 15 - 20
• Length of involvement – 6 - 9 mos.

15. Program Goals
• Provide quality health care along the
continuum
• Decrease inpatient days
• Decrease re-admissions
• Improve coordination of care
• Enhance the client’s ability for self-care
• Contain cost to the client and the system

16. Foundational Principles
• Desire to be well
• Self-Determination
• Partnership development based on mutual
respect
• Client values guide all clinical decisions
• Client responsibility for process &
outcomes

17. Practice Theories
• Behavior Change Theory
• Motivational Interviewing
• Self-Advocacy
• Self-Management

18. Why both Nurses and Social Workers?
• Clients with complex medical conditions may
also be facing financial, social and emotional
stressors negatively impacting physical health
• Partnership between the NCM, with expertise
in health and illness, and the SWCM, with
expertise in psychosocial assessment and
knowledge of community resources, is key to
achieving outcomes

19. Advocacy
Education
Care Planning
Coaching
Completion of
Advance Directives
Ongoing Monitoring
& Support
Comprehensive Assessment
Symptom Identification
& Management
Medication Management
Participation in PCP &
SCP Office Visits
Screening Against High
Risk Criteria
Collaboration with
Physicians & Health
Care Professionals
Housing Stabilization
Assessment of Finances
& Available Resources
Insurance Access
Assessment of Long Term
Care Needs
Community Resource
Identification & Mobilization
Collaboration with
Community Agencies
How does the partnership look?
NCM SWCM

20. Program Outcomes
Since 2003, CBCM program effectiveness has
been measured through analysis of:
•Utilization / costs (comparing 12 months prior
to CBCM v. Annualized data after CBCM
involvement)
•Client satisfaction
•Clinical quality

21. ER Visits
(avg. 177/year)

22. Inpatient Admissions
(avg. 120/year)

23. Inpatient Days
(avg. 708/year)

24. Costs
(avg. $2.22 million/year)

25. Client Satisfaction
High levels of satisfaction with services:
–“Very Good” or “Excellent” in 94% of survey
questions
– 37 % response rate
(2012)

26. TOTAL SCORE (on a 4.0 scale) 3.5
(2012)
General Health (11 indicators) 3.4
Smoking (3 indicators) 4.0
Diabetes Mellitus (11 indicators) 2.5
Congestive Heart Failure
(7 indicators)
4.0
Clinical Quality Outcomes

27. General Health indicators
11 indicators, including:
•Advance Care Planning
•Primary Care Provider Interface
•Breast, Cervical & Colo-rectal cancer screenings
•Flu vaccine
•Pneumovax
•Lipid profile
•Single Pharmacy use
•Depression screening
•Osteoporosis screening

28. Smoking indicators
3 indicators, including:
•Prevalence
•Assess readiness to quit
•Cessation assistance offered

29. Diabetes Mellitus indicators
11 indicators, including:
•Annual eye exam
•Foot care
•Hemoglobin A1C
•Comprehensive foot exam
•Dental care
•Blood pressure
•LDL
•Kidney function monitoring
•Estimated GFR

30. Congestive Heart Failure indicators
7 indicators, including:
•Weight monitoring
•Symptom management
•ACE-I or ARB
•Beta blocker
•Fluid and diet recommendations
•Echocardiogram

31. “. . . since many of the outcomes being
measured are more directly tied to medical
factors, social work case managers, unlike our
nurse counterparts, face challenges in validating
our impact on these outcomes.”
(taken from Abstract)

32. In 2007, the SWCMs developed an
outcomes tracking instrument specific to
our program, clients and community, in
order that we might:
In order to address this need…
1. Document the unique contributions made by
Social Workers within our department.
2. Allow us to engage in research about our
practice to determine what works most
effectively.
3. Better incorporate evidenced based practice
models as well as contribute toward this body
of knowledge.

33. Methods
• Random selection of closed cases and current
cases (n=30)
• Each case was carefully reviewed by both
SWCMs
• Data was collected concerning SWCM
involvement in each case
• The data was coded and notes were kept in
separate documents
• A narrative analysis was employed to identify
specific and general ways SWCMs have worked
with clients

34. Methods (Cont.)
Through using the process of “mining” the
data, we were able to:
• Identify patterns and themes that
emerged from the data.
• Coded and sorted data according to
these patterns and themes.
• Once developed, categories were
expanded and collapsed as needed.

35. Methods (Cont.)
This iterative process included:
– Multiple meetings
– Further review of notes
– Brainstorming from collective experience
This process resulted in:
– 16 main issue categories
– 2 or more potential outcomes for each
– 6 reasons for non-achievement

36. SWCM Outcome Tracking Tool
(Sample)
Social Work Case Management Outcomes (Page 1 of 3)
Study Subject #______________ Completed By:____________
Date:__________
Issue Identified Outcome: Identified by:
(Client/Other)
Date
Outcome:
Achieved /
Not Achv*
Date
1. Housing 1.0 Housing/shelter
1.1 Alternate housing/
shelter
1.2 Other ____________
0  1 ______
  ______
  ______
0 *____
  ____
  ____
2. Nutrition/
Food Support
2.0 Emergency food
resources
2.1 Home delivered meals
2.2 Senior meal program
2.3 FoodShare benefits
2.4 Increase FoodShare
benefits
2.5 Other _____________
0  1 ______
  ______
  ______
  ______
  ______
  ______
0 *____
  ____
  ____
  ____
  ____
  ____

37. 6. Utility Services  6.0 Phone
 6.1 Electricity / Heat
 6.2 Prevention of utility disconnection
 6.3 Other_____________
7. Education  7.0 Enroll client in school
 7.1 Enroll child in school
 7.2 Alternate educational opportunities
 7.3 Other _____________
3. Clothing/
Household Goods
 3.0 Appliances
 3.1 Furniture
 3.2 Clothing
 3.3 Household goods
 3.4 Fan/Air conditioner
 3.5 Other ____________
4. Financial  4.0 Income
 4.1 Increase income
 4.2 Debt resolution
 4.3 Money management
 4.4 Other _____________
5.Transportation  5.0 Transportation for medical purposes
 5.1 Transportation for medical and/or community purposes
 5.2 Other _____________

38. 8. Employment  8.0 Employment
 8.1 Alternate employment
 8.2 Prevention of job loss
 8.3 Other ______________
9. Caregiver Support  9.0 Coping enhancement strategies
 9.1 Respite care
 9.2 Other ________________
10. Health Care
Access
 10.0 Health insurance
 10.8 Alternate health insurance
 10.1 Additional health insurance
 10.2 Prescription coverage
 10.3 Additional prescription coverage
 10.4 Healthcare provider
 10.5 Alternate healthcare provider
 10.6 Enhance relationship with healthcare provider
 10.7 Other ____________
11. Coping  11.0 Coping enhancement strategies
 11.1 Other _____________
12. AODA/ Mental
Health
 12.0 AODA counseling / intervention
 12.1 Mental Health counseling / intervention
 12.2 AODA & Mental Health counseling / intervention
 12.3 Other _____________

39. 14. Advance Directives
(AD)
 14.0 Advance Directives
 14.1 Revise Advance Directives
 14.2 Other _____________
15. Hospice/
Palliative Care
 15.0 Hospice care services
 15.1 Palliative care services
 15.2 Other _____________
16. Supportive in-home
services
 16.0 Personal care
 16.1 Housekeeping
 16.2 Child care Assistance
 16.3 Emergency response system – (e.g. Life Line)
 16.4 Other_____________
17. Other: _____________  17.0 _______________
 17.1 _______________
 17.2 _______________
13. Safety  13.0 Improved safety in the home
 13.1 Improved safety in the community
 13.2 Other _____________

40. 1 Client no longer needs/wants assistance
2 Client rejects identified resources
3 Client not eligible for resources at this time
4 Client wishes to address need at a later date
5 No resource available at this time
6 Client’s case closed prior to achieving the
outcome
7 Other ______________________
*Reasons for “Not Achieved”

41. Considerations & Logistics
of data collection
• Some “professional judgment” and subjectivity
involved with the identification and tracking of
outcomes
• During tool development , we decided against a
“partially achieved” category to eliminate some
subjectivity
• Paper tool developed 2007; computerized into
program intake database 2008; volume of data
became significant 2009
• Almost all clients have multiple outcomes
• Not 100% of client work/outcomes are accounted for

42. WHAT WE FOUND
Social Work Case Manager Outcomes
Least prevalent psychosocial/financial need
issues (n < 13):
– Education
– Employment
– Caregiver Support
– Coping
– AODA/Mental Health
– Safety
– Advance Directives
– Hospice/Palliative Care
(through February 2013)

43. WHAT WE FOUND
Social Work Case Manager Outcomes
Most prevalent psychosocial/financial need
issues & percent of achieved outcomes:
– Health Care Access (n=120) – 80%
– Housing (n=57) – 46%
– Financial (n=55) – 56%
– Supportive in-home services (n=44) – 48%
– Clothing/Household Goods (n=41) – 76%
– Utility Services (n=38) – 82%
– Transportation (n=36) – 78%
– Nutrition/Food Support (n=30) – 70%
(through February 2013)

44. Health Care Access outcomes
Identified outcome (# achieved/total # of instances) achievement %
Total outcomes (96/120) - 80%
Individual outcomes:
•Health insurance (13/15) - 87%
•Alternate health insurance (6/11) - 55%
•Additional health insurance (29/35) - 83%
•Prescription coverage (16/16) - 100%
•Additional prescription coverage (19/24) - 79%
•Healthcare provider (7/9) - 78%
•Alternate healthcare provider (4/8) - 50%
•Other (continue health insurance) (2/2) - 100%

45. Housing outcomes
Total outcomes (26/57) - 46%
Individual outcomes:
•Housing/shelter (3/3) - 100%
•Alternate housing/shelter (22/48) - 46%
•Other (i.e. avoid eviction, obtain rent
assistance, plumbing repairs) (1/6) - 17%

46. Financial outcomes
Total outcomes (31/55) - 56%
Individual outcomes:
•Income (6/10) - 60%
•Increase income (7/13) - 54%
•Debt resolution (14/22) - 64%
•Money Management (3/9) - 33%

47. Supportive in-home services outcomes
Total outcomes (21/44) - 48%
Individual outcomes:
•Personal care (10/23) - 43%
•Housekeeping (5/13) - 38%
•Emergency Response system (2/3) - 67%
•Other (Long-term community based case
management program/services) (4/5) - 80%

48. Clothing/Household Goods outcomes
Total outcomes (31/41) - 76%
Individual outcomes:
•Appliances (3/7) - 43%
•Furniture (14/15) - 93%
•Clothing (4/6) - 67%
•Household Goods (9/11) - 82%
•Fan/Air conditioner (1/2) - 50%

49. Utility Services outcomes
Total outcomes (31/38) - 82%
Individual outcomes:
•Phone (13/13) - 100%
•Electricity/Heat (10/15) - 67%
•Prevention of disconnection (8/9) - 89%

50. Transportation outcomes
Total outcomes (28/36) - 78%
Individual outcomes:
•Transportation for medical (13/16) - 82%
•Transportation for community (14/19) - 74%

51. Nutrition/Food Support outcomes
Total outcomes (21/30) - 70%
Individual outcomes:
•Emergency Food resources (6/8) - 75%
•Home delivered meals (5/6) - 83%
•Senior Meal program (0/2) - 0%
•Food Share benefits (8/11) - 73%
•Increase Food Share benefits (1/2) - 50%
•Other (continue Food Share benefit) (1/1) - 100%

52. Next steps/opportunities
• Explore equating social work outcomes to
financial data thereby further validating social
work’s impact on an increasingly costly health
care system
• Analyze changing trends in client issues over
time; reasons of “Not Achieved”; Achievement
rates correlated to who identified the
outcome; length of time needed to “Achieve”
• Other? Questions or suggestions from
attendees

53. Acknowledgements & References
• Auerbach, C., Mason, S.E., & Heft LaPorte, H. (2007).
Evidence that supports the value of social work in
hospitals. Social Work in Health Care. 44(4), 17-32.
• Collins, Stacy. (2011). Accountable Care
Organizations (ACOs): Opportunities for the Social
Work Profession. NASW Practice Perspectives, Fall
issue, September 2011.
• Williams, Eva. SWCM with Aurora’s Community
Based Case Management from 2002 – 2008.

54. Contact Information
Email
Carlos.estrada@aurora.org
Maria.champagne@aurora.org
Mail
Community Based Case Management
Aurora Health Care
950 N. 12th
St., 4th
Floor
Milwaukee, WI 53233
Telephone
414-219-5400