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Canadian Association of Occupational Therapists
TOWARD BEST PRACTICES FOR CASELOAD ASSIGNMENT
AND MANAGEMENT FOR OCCUPATIONAL THERAPY IN
CANADA
FINAL REPORT
Prepared by
in collaboration with
D. Parker-Taillon and Associates
TABLE OF CONTENTS
EXECUTIVE SUMMARY ................................................................................................. i
1.0 INTRODUCTION .................................................................................................. 1
1.1 Background........................................................................................................ 1
1.2 Scope of the Project........................................................................................... 2
1.3 Methodology ...................................................................................................... 2
2.0 CASELOAD MANAGEMENT AND RESOURCE ALLOCATION ........................ 3
2.1 What is Caseload Management? ....................................................................... 3
2.2 How does Resource Allocation Impact the Delivery of Health Services?........... 3
2.3 How does Resource Allocation in Health Service relate to Caseload
Assignment and Management? ......................................................................... 5
2.4 Why is Caseload Management of Interest in 2005? .......................................... 5
3.0 CURRENT STATUS OF CASELOAD MANAGEMENT....................................... 7
3.1 What is Happening on the International Front?.................................................. 7
3.2 What Findings Emerged from the Targeted International Scan and Review of
the Literature?.................................................................................................... 8
4.0 TOWARD BEST PRACTICE IN CASELOAD MANAGEMENT FOR
OCCUPATIONAL THERAPY IN CANADA........................................................ 19
4.1 What can be Learned about Best Practices in Caseload Management for
Occupational Therapy in Canada? .................................................................. 19
4.2 What are the Recommendations for Further Work on Caseload Management
for Occupational Therapy in Canada? ............................................................. 21
Appendix 1: Caseload Assignment and Management ............................................. 23
Appendix 2: Caseload Index Factors in Mental Health ............................................ 25
Appendix 3: Caseload Management Frameworks in Occupational Therapy ........ 26
Appendix 4: Survey on Caseload Assignment and Management ........................... 29
GLOSSARY .................................................................................................................. 31
REFERENCES.............................................................................................................. 32
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EXECUTIVE SUMMARY
Caseload Assignment and Management
In late 2004, the Canadian Association of Occupational Therapists (CAOT) developed and received
Health Canada funding for a project to examine best practices in occupational therapy caseload
assignment and management.
“Caseload assignment and management involves the productive and efficient use of
time and resources to maximize and achieve successful client outcomes. The
systematic synthesis of client and service information should assist to design effective
and efficient service delivery. Such a delivery system should accomplish positive
outcomes within available health agency resources and professional guidelines”
(Cavouras, 2003)
An effective caseload management framework should reflect the diversity of occupational therapy
practice and the importance of clinical reasoning as the foundation of service delivery. This report is to
be considered as a first step towards a possibly larger project to develop a framework that integrates
evidence-based practices to shape best practices in caseload assignment and management in
Canada.
The Methodology
The methodology for the project consisted of four steps:
• Focussed search and review of the literature related to caseload assignment and management
• Environmental scan of international associations in selected health professions
• Targeted CAOT stakeholder questionnaire
• Analysis and development of report
The Key Findings
As a result of the focussed review of the literature and the international scan undertaken for this
report, a number of key findings about caseload management for occupational therapy in Canada
emerged. These findings, in summary, include:
• Caseload management is an issue in health services and an emerging issue within occupational
therapy. New management processes and tools are now being explored and developed on the
international scene. However there is limited progress in developing case management models
with adequate rigor to be applied at a system or local level.
• Federal-provincial-territorial (F/P/T) governments are focusing on a 10-year plan to strengthen
health services in Canada. CIHI is charged to collect and provide valid, reliable and meaningful
information to government, service agencies and service managers.
• In the past, caseload models for occupational therapy in Canada have tended to focus on setting
caseload guidelines based on averages for indicators that reflect the work actually being done.
The trend appears to be towards using more of a population-based approach that seeks to
understand and quantify workload (and hence human resource requirements) in relation to the
needs of a specific population.
• There is no clear direction for caseload management in occupational therapy; in fact, more
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research and development is definitely required. Using workforce management and caseload
information should improve the access Canadians have to occupational therapy services.
• CAOT promotes best practice in the context of having procedures that are believed to result in
the most efficient provision of services while ensuring evidence-based practice, clinical reasoning,
and accountability are major contributing elements. This approach to best practice should ensure
that the organization of occupational therapy services is both efficient and effective.
The Proposed Guiding Principles
As a result of the work of this report, a number of “guiding principles” have been identified to better
inform the future development of best practice in caseload management in occupational therapy in
Canada.
• Evidence-based occupational therapy: client-centred enablement of occupation based on
client information and a critical review of relevant research, expert consensus and past
experience
• Cost-Effectiveness: providing services in the most efficient and effective manner that is
consistent with acceptable professional standards for service delivery
• Accountability: enabling understanding, assessment and measurement of system
performance that facilitates continuous improvement of access, results, resource use, and
service delivery itself
• Professional Leadership and Expert Judgment: Taking a leadership role in identifying
clinically relevant and caseload assignment and management models that are appropriate to
occupational therapy practice
• Comprehensiveness: recognizes the need for, and importance of, indirect as well as direct
activities in the provision of services
• Flexibility: Recognizes and reflects the diversity of delivery models in use
The Suggested Approach
The report suggests that any caseload management approach for occupational therapy in Canada
should be guided by principles and respect several critical considerations, including that the approach
should be:
• Retrospective data-based: Without data, professional judgements will be based on intuition and
perception. Best practice demands much more. There is an ongoing need for meaningful data
and new caseload measurements in reliable and computerized formats. Database systems are
needed to provide accurate, reliable, timely and accessible real-time information. Given the
development of more valid and reliable management information systems at local, provincial and
federal levels, retrospective data is now more readily available.
• Population-specific: The practice of occupational therapy engages various client populations,
each with its unique needs and challenges. The findings suggest that retrospective data is most
valid and reliable when considered in relation to clinically relevant and appropriate client case
groups. Such case groups are best identified by expert occupational therapists given data
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availability and caseload sensitivity. In developing a caseload management approach factors
should be considered such as population characteristics, access and demand patterns, service
delivery approaches to specific populations, and population outcomes.
• Context-specific: The context of the occupational therapy service should shape the approach to
caseload management. Given the range of factors reported in the literature to be relevant to
caseload management it is important to carefully select and quantify the most critical factors to
specific context of practice for occupational therapy. Although several factors may be context-
specific, case complexity, and service models or approaches appear most common across
reviewed professional models. Caseload models should always consider service and client
outcomes. When expected outcomes for case groups are not met, caseload assignment
processes should be re-evaluated and re-aligned with client needs and resource priorities.
The Recommendations
Based on the key findings of this inquiry, a number of recommendations for next steps are suggested
below.
1. CAOT should conduct a survey of Canadian practice settings to develop an inventory of
current caseload management practices in occupational therapy. (Year 1)
2. CAOT should host a consensus workshop on best practice for caseload management in
occupational therapy in Canada. This initiative should include development of a pre-workshop
discussion paper with survey results, proposed principles and guidelines, suggested case
groups and caseload management factors, and a range of approaches. (Year 2)
3. CAOT should consider commissioning specific research to develop valid and reliable caseload
management frameworks/models that are specific to major occupational therapy case groups.
(Year 2)
4. CAOT should facilitate the development of a framework that integrates evidence-based
practices to shape best practices in caseload assignment and management in occupational
therapy in Canada. Clinical reasoning and accountability are viewed as integral to this
caseload management framework. (Year 2)
5. The occupational therapy community should initiate and continue to conduct research to
evaluate the impact of caseload management on service, practitioner and client outcomes.
(Year 3)
In summary, it appears that the need for appropriate caseload management within occupational
therapy, and other health services, is widely accepted. Occupational therapists may well be prepared
to move forward with caseload management approaches that recognize clinical reasoning and
accountability as integral to the development of best practices.
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1.0 INTRODUCTION
In late 2004, the Canadian Association of Occupational Therapists (CAOT) developed and
received Health Canada funding for a project to examine best practices in occupational
therapy caseload assignment and management.
1.1 Background
In 2002, CAOT identified a shortage in the occupational therapy workforce (von Zweck,
2002). Since that time CAOT has undertaken several projects to move ahead with its Health
Human Resources Strategy (CAOT, 2003; 2004; 2004a; 2004b).
Currently occupational therapists assume large caseloads without a framework or guidelines
for caseload assignment and management. To date, decisions regarding caseload
assignment and management are made arbitrarily and often the staffing of occupational
therapists is dependent on current budget allocations rather than on a framework that
integrates evidence to shape best practices in caseload assignment and management.
CAOT recognizes the need for a framework to guide decisions concerning human resource
planning and deployment. An effective caseload management framework should reflect the
diversity of occupational therapy practice and the importance of clinical reasoning as the
foundation of service delivery. Such a framework will ultimately benefit the people of Canada
by ensuring adequate and equitable access to services in their own communities.
Federal/provincial/territorial and regional health planners will have a national approach to
guide occupational therapy human resource planning in all geographic areas of Canada.
Through the Pan-Canadian Health Human Resources Strategy, CAOT is privileged to work in
partnership with Health Canada on several initiatives. CAOT has been selected for the
Health Human Resources Databases Development Project (HRRDDP) offered in partnership
with Canadian Institute for Health Information (CIHI). CAOT is a Steering Committee
member on both the Initiative on Enhancing Interdisciplinary Collaboration in Primary Health
Care as well as the Canadian Collaborative Mental Health Initiative that are funded through a
Primary Health Care Transition contribution agreement.
As CAOT moves forward with its strategy to secure an effective occupational therapy
workforce in Canada, it will need to collect evidence and knowledge of best practices among
other professions. CAOT would like to investigate best practices for caseload assignment and
management in Canada and internationally among a selected group of health professions.
It is for this reason that CAOT is pleased to be working collaboratively with Health Canada in
pursuit of another component of our health human resources strategy in occupational
therapy: caseload management. This report is to be considered as a first step towards a
possibly larger project to develop a framework for caseload management for occupational
therapy in Canada.
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1.2 Scope of the Project
As one component of the CAOT Health Human Resources Strategy, CAOT commissioned
the development of this background paper based on a review of published information and
literature that provides an overview of best practices in caseload assignment and
management, their utilization, and applicability to the diversity of occupational therapy
practices. Specifically, the scope of the report includes:
• An environmental scan of the current issues in occupational therapy caseload
assignment and management including the identification of the needs of the
occupational therapists and other relevant stakeholders such as Federal, provincial,
territorial and regional governments and health planning organizations.
• An overview of current frameworks in caseload assignment and management gleaned
from the review of targeted information and literature related to best practices in
caseload assignment and management and applicability of standards/frameworks
developed by selected professions or health service sectors.
• Identification of best practices that can be further enhanced to increase their usefulness
in the development of best practices in caseload assignment and management in
occupational therapy in Canada.
• Recommendations for further work on caseload assignment and management as it
pertains to occupational therapy in Canada.
This project also provides a strategic communication tool to assist CAOT with presenting key
findings from this paper to information holders such as the Canadian Institute for Health
Information (CIHI), Health Canada, Human Resources Development Canada (HRDC),
provincial regulatory organizations, Statistics Canada, and national and international
professional associations.
1.3 Methodology
This report was developed by external consultants (Management Dimensions, in conjunction
with D. Parker-Taillon and Associates) under the management and guidance of the Director
of Standards and Professional Affairs at CAOT (CAOT Key Contact). The project
methodology consisted of four steps:
Search and Review of the Literature
A focussed search and review of the literature related to caseload assignment and
management in nursing, speech-language pathology, physiotherapy, occupational therapy
and mental health was undertaken. Search strategies included:
• On-line searching of the databases Medline/Pubmed and CINAHL;
• Reviewing information provided by CAOT; and
• Reviewing information recommended by international contacts from the professional
associations.
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Environmental Scan of International Associations in Selected Health Professions
Direct email contact was made with associations representing selected health professions
internationally to obtain information on current work related to the development of
frameworks/guidelines/standards in caseload assignment and management. The selected
health professions included occupational therapy, physiotherapy and speech language
pathology in Australia, New Zealand, United Kingdom and the United States.
CAOT Stakeholder Questionnaire
A short questionnaire was developed and sent to a list of 20 individuals provided by CAOT
who had expressed an interest in caseload assignment and management. The purpose of
the questionnaire was to obtain selected perspectives within the Canadian environment on
unpublished approaches in caseload management and the need for further work in this area.
Analysis and Development of Report
The findings from the literature review, international environmental scan, and CAOT
stakeholder questionnaire were analyzed and the draft report developed. The draft report
was submitted to the CAOT Key Contact for feedback and revised as necessary prior to final
submission.
2.0 CASELOAD MANAGEMENT AND RESOURCE ALLOCATION
2.1 What is Caseload Management?
Caseload assignment and management involves the productive and efficient use of time and
resources to maximize and achieve successful client outcomes. The systematic synthesis of
client and service information should assist to design effective and efficient service delivery.
Such a delivery system should accomplish positive outcomes within available health agency
resources and professional guidelines (Cavouras, 2003).
For the purposes of this report the term caseload management will be used and is seen as
including the subsequent completion of caseload assignment. Definitions for additional key
terms used in this paper related to caseload management are included in the Glossary.
2.2 How does Resource Allocation Impact the Delivery of Health Services?
In future, the demand for health services will continue to exceed the money available. Indeed,
the pressure on resources will increase as the population ages, and technological
development expands possibilities. It is not wise to assume that the distribution of resources
that has evolved historically is either efficient, equitable or appropriate in future delivery of
health services. There is a pressing need to improve the allocation of public funds for health
services that will be effective in improving population health.
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The CIHI Roadmap Initiative (2000) incorporates a commitment to develop better information
on health and the health system. An example of a project that may, in the long term, better
inform provincial or regional resource allocation decisions include the Health Indicators
Project. This project will develop information to support Regional Health Authorities across
the country in monitoring progress in improving and maintaining the health of the population
and the functioning of the health system. Comparative information is being created on
population health, health services, health determinants and characteristics of the health
system.
There is a paucity of literature related to population needs for occupational therapy,
effectiveness of interventions, appropriate benchmarking and resource allocation
methodologies. This opens the way to processes being developed that rely on expert
judgement at a time when there is fierce competition for limited resources. Little information
exists on specific funding models for occupational therapy and rehabilitation in general.
However, there is reason to carefully consider the particular impact of applying a general
population-based model to such health services. An unpublished Manitoba Health report
(2001) on rehabilitation services, of which occupational therapy is one, summarizes the
general references to rehabilitation funding issues found in the literature.
• Rehabilitation cost patterns and resource intensity weights differ from acute episodic
care (Australia, CIHI Rehabilitation Standards Project).
• Secure funding levels for rehabilitation services within hospital funding allocations are
important to service viability (Ontario).
• Core rehabilitation services should be defined, funded within allocations and evident in
regional programs (Manitoba, Ontario, BC, New Zealand, United Kingdom).
• Service standards, levels of service and evidence-based practice guidelines should
drive funding decisions (New Zealand).
• The link between public-private service mix should be explored, in light of its impact on
core services and public funding (Alberta, Ontario)
• It may make sense to transfer some outpatient hospital funding for rehabilitation to
new primary care or community rehabilitation service models (New Zealand, Great
Britain, Alberta, Ontario).
• Regional initiatives should be well integrated with provincial and inter-departmental
rehabilitation programs/services for adults and children (Alberta, Manitoba,
Saskatchewan, British Columbia).
There is a growing need to consider health and service needs of the population, evidence of
effectiveness and the socio-political and economic impact of alternative resource allocation
scenarios (Kazanjian, A., Hebert, M., Wood L. & Rahim-Jamal, S., 1999).
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2.3 How does Resource Allocation in Health Service relate to Caseload Assignment
and Management?
Regional health agencies (RHA’s) have been established in many jurisdictions across the
country. This structural change increases the accountability and management of health
services at the regional level. Under this model, usually each region can access funding
based on population health needs.
Past work in Great Britain1 describes resource allocation to health authorities on the basis of
relative needs of their populations. The weighted capitation formula is under review to
produce a fairer formula to determine each health authority’s share of available resources.
Such fairness requires that key concerns are addressed such as demographics; variable
costs of serving ethic and rural populations; needs-related issues for specific service
populations and the impact of the private sector. The new NHS uses the current formula to
set target allocations for patient care groups. Ongoing studies seek to develop models that
establish equitable target staffing levels (Executive Summary, DOH). The present caseload
model uses specific data and factors sensitive to the population served. Through examining
caseloads and work patterns, it is suggested that staff allocations should be determined for
each caseload type.
Under a regional funding system that is population-based, resources are usually distributed to
regions according to the relative health expenditure needs of the population. Therefore, in
theory, equal funding would result if individuals in the population had similar levels of health
service needs. It is widely recognized that significant differences in health service needs
occur due to variations in age, gender and socio-economic status. Regional health agencies
need to have excellent utilization and cost data to support population based funding.
In addition, data collection should include information sensitive to the complexities of the
occupational therapy caseload, not merely reflective of medical programs and case
classification. If funding for occupational therapy becomes part of a population-based
allocation to regions without standards or service levels clearly defined, resource allocation to
occupational therapy will be unpredictable and access to service may well decrease.
2.4 Why is Caseload Management of Interest in 2005?
In Canada there is a renewed sense of urgency and shared effort to make the health service
system more responsive and sustainable (Boshoff, 2003; Federal 10-Year Health plan, 2004;
CIHI 2002). Emerging to the forefront of discussions are issues of reducing waiting times and
improving access to services. To achieve better system performance, Canadians have been
promised continued accountability and the advancement of best practice.
Jongbled and Wendland (2002) suggest that the Canadian Public Insurance System controls
cost through provincial regulation and cost controls that limit the capacity of personnel and
health facilities. The service impact is directly experienced by practitioners and service
agencies. Once service mandates are determined and resources are allocated, access is a
1
Refers to working papers developed by Resource Allocation Working Party in Great Britain (1989-current).
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question of organization and management. Caseload Management has been promoted as
an effective tool for service planning and accountable client care. However, the needs for
caseload management vary among key stakeholders - clients, occupational therapists,
service managers, service agencies and health planners. Table 1 presents the needs for
caseload assignment and management from the perspective of different stakeholders.
Table 1: Stakeholder Needs for Caseload Assignment and Management
Stakeholder Needs for Caseload Assignment and Management
Group
Clients • Clear service expectations of access, priorities and outcome
• Transparent style and focus of treatment experience
• Delivery of quality services
Occupational • Service standards
Therapists • Focus on client outcomes
• Professional work experience and environment
• Practice management of service demands
• Individual service efficacy
• Service and practice diversity
• Guidance for caseloads in specific program areas
• Clarify reasonable workloads
• Support for decisions related to priorities and appropriate referrals
Managers • Proactive workforce management
• Determination of service role and capacity
• Planning new or changing services
• Monitoring service efficacy
• Fairness and equity in workload distribution
• Monitoring staff performance
• Negotiation for service resources within system
• Appropriate allocation of resources
• Predict staffing levels for individual programs
• Costing of service delivery
• Clarify reasonable workloads
• Recruit and retain staff
Service • Direct response to public on access and service standards
Agencies • Determining appropriateness of services
• Predictable service costs and volume
• Effective workforce management
• Impact of work environment on client and staff satisfaction
• Negotiating contracts for service delivery
• Best use of available resources
• Support for decisions related to allocation of resources
• Clarify reasonable workloads
• Delivery of quality services
• Determination of service role and capacity
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Stakeholder Needs for Caseload Assignment and Management
Group
Health Service • Effective workforce management
Planners • Budgeting and funding services
• Better matching of staffing levels to client need
• Optimal patient outcomes and utilization of professional staff
• Delivery of quality services
• Determination of service role and capacity
Caseload is clearly relevant to workforce planning, client service provision and staff
management. Health service planners, service agencies and service managers are being
challenged to improve their understanding of workforce and service management strategies
to achieve better service efficiency.
Occupational therapists believe in client-centered practice and are reluctant to compromise
clinical autonomy for improved service utilization. Rappolt et al (2004) reported from data in
a 2003 Ontario survey that "occupation therapists are, as professionals who remain confident
in their ability to provide care in the best interests of their clients, consistent with professional
norms"(p.12). Their 2004 survey results however, indicate that there is a potential for conflict,
in particular if third party requirements are perceived to erode clinical autonomy.
Boshoff (2003) suggests that, although occupational therapists have a strong commitment to
provide quality clinical services, there is a need for more attention to streamline and
strengthen service delivery systems. Caseload assignment and management is one
approach that attempts to balance quality interventions with cost effectiveness.
3.0 CURRENT STATUS OF CASELOAD MANAGEMENT
This section presents the findings of the focussed search and review of the literature, as well
as the targeted international scan, related to caseload assignment and management in
nursing, mental health, speech-language pathology, physiotherapy, and occupational
therapy.
3.1 What is Happening on the International Front?
In order to ascertain what is happening on the international front related to caseload
management, email contact was made with associations representing selected health
professions internationally including occupational therapy, physiotherapy, and speech
language pathology in Australia, New Zealand, United Kingdom and the United States.
A total of 12 organizations were contacted and replies were received from 11 of these,
representing a 91% response rate. Overall the findings indicated that, while the subject of
caseload management is an issue of interest for many of the organizations, the majority do
not have caseload guidelines in place. Some of the respondents indicated that factors such
as acuity of the condition, type of services provided and nature of the setting made it difficult
to provide caseload guidelines. A few organizations (n=4) indicated they have recently
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initiated projects related to this topic and would be interested in the outcome of the CAOT
paper. The results of the international environmental scan are summarized in Appendix 1.
Documents provided by the respondents were reviewed and are discussed in the next
section under the relevant profession.
3.2 What Findings Emerged from the Targeted International Scan and Review of the
Literature?
Nursing
Nursing literature in recent years focuses on the relationship between quality of patient care,
nursing staffing levels and nursing skill mix. This direction has shifted attention from cost
efficiencies to patient outcomes. Current workforce planning and staffing plans are strongly
influenced by health service policies and regulations that strive to implement safe staffing
standards (Cavouras, 2003). In the United States these standards address three major
factors: scope of practice, nurse to patient ratios and patient acuity (Dumpel, 2004).
Three nursing approaches are commonly described that outline the impact of the scope of
practice on the role and number of nursing staff. Under functional nursing, care is organized
and work assigned by tasks, not patients, in a drive for cost efficiency. Team nursing is a
more patient-oriented approach with each nursing team assuming responsibility for a group of
patients. Teams are led by an RN who assigns work to team members who accomplish the
required care during a work shift. Primary nursing has a higher percentage of RN staff, each
of whom is responsible for the total and comprehensive care of assigned patients during the
length of stay or care episode. This integrated model is seen to avoid fragmentation of care
(Dumpel, 2004).
In 1999 in California, legislation was adopted that will see minimum nurse to patient staffing
ratios established. These ratios will be adjusted based on the nursing care requirements
determined under the standardized Patient Classification System (PCS). The patient care
indicators required under PCS include: severity of illness (acuity), need for specialized
judgment and equipment, complexity of clinical judgment needed to design, implement and
evaluate a patient care plan, ability for self-care, and licensure for personal required care
(Dumpel, 2004, p.19). Results of this regulated approach to staffing ratios are still being
evaluated.
Cavouras (2003) promotes evidence-based staffing using a reliable and valued method. The
author describes three common staffing methodologies for nursing.
• Hour per patient day staffing (HPPD)
o In use by unit managers in organizations where patient needs are relatively stable
o Monitors variations in patient populations
o Supplements HPPD staffing when patient needs increase
o Demands high staff-administration trust
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• Ratio-based staffing
o Establishes ratios under organization policy or as mandated by regulation
o Attempts to better respond to predicted variations in patient care needs by setting
staffing ratios using patient and service data
o Incorporates, in some instances, requirements for patient care, nursing services and
competency
• Acuity-based staffing
o Uses nearly real-time workload information including the nursing interventions applied,
staffing skill-mix and hours of care
o Depends on a valid and timely workload model that is computerized and provides
immediate reports
o Based on reliable patient classification systems to capture changes in patient
populations and clinical interventions throughout the care episode
o Recognized as time-consuming and expensive given the computerized workload
requirements
In the case of nursing, with its 24-7 scheduling, dynamic systems are required with the
capacity to adjust staffing on an as-needed basis. To achieve this service responsiveness,
staffing allocation should depend on expert staff-RN judgment to complement staffing ratio or
acuity based systems (Killeen, 2004). Hader (2002) describes a straightforward seven-
method approach to staffing assignment in a large magnet-designated health system in the
United States.
1. Determine acuity (patient mix) and workload for defined clinical populations or patient
care units.
2. Determine how and where staff members spend their time.
3. Identify trends in patient populations, staffing patterns, workload and care practices.
4. Develop efficient charting and reporting systems.
5. Maintain good staff utilization information.
6. Effectively allocate limited resources.
7. Benchmark services to support decisions with finance.
There is a lack of consensus within the health service system on the best staffing models for
nursing. While most approaches are data-based, many factors determine the approach
preferred by organizations including: the nursing model, patient population, patient acuity,
service priorities, patient outcomes, and available financial resources. In addition, health
planners must keep the public-private dynamic in mind when evaluating models reported
from the United States health system and comparing them to the Canadian system. It should
be noted that nursing care significantly differs from occupational therapy services in the type
of client needs and service demands, interventions and service approaches, expected
outcomes, scheduling, and staffing patterns.
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Mental Health
Caseload management, as an approach to the delivery of health services, is often discussed
in relation to clinical efficacy and cost effectiveness (King, Graham, and Le Bas, 2004).
Within community mental health, continuity of care can be achieved when case management
acts as a single point of contact for service access. Although the caseload concept has
different applications within mental health, a better understanding of the procedures for
determining and assigning caseload can assist workforce planning, service provision and
staff management.
King et al (2004) describes three caseload index models used within the Australian mental
health system. Occupational therapists are cited as one of the many health service
professionals contributing clinical case management and impacted by these specific caseload
assignment methodologies. Each model uses selected factors from among seven caseload
measurement variables: contact frequency, response difficulty, intervention type,
competence/seniority, caseload maturity, location of clients, and roles other than case
management (p. 457). Appendix 2 describes the seven factors with specific advantages and
limitations identified within the Australian caseload index model in mental health.
Model 1: Melbourne Model
• Developed in Melbourne, Australia within the Victoria Area Mental Health Service
• Based on consideration of contact data
• Primarily focuses on having equity between case managers
• Determines patterns of care with three levels of contact frequency: high, medium and low
• Uses routinely collected data recorded in an electronic database with fields including date,
date of contact, duration, location and other people involved
• Calculates a caseload score recognizing the different intensities of staff time required and
the relationship among the contact categories
• Completes caseload assignments by adjusting the mix of high, medium and low intensity
case types to ensure each case manager has an equitable caseload
Model 2: Queensland Model
• Developed at the University of Queensland from previous work in Victoria
• Based on case distribution through assigning a response difficulty rating at the time of
client assessment as high, medium or low
• Enters selected factors into an algorithm and includes the time allotted, caseload maturity
and seniority of the staff member
• Describes aspects of case weighting as somewhat arbitrary and the process as time-
consuming
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• Allows the team leader to achieve caseload equity with each case manager assigned
relatively equal numbers of high, medium and low response difficulty clients
Model 3: Caseload Index Approach
• Identified as a comparative index and does not entail normative standards
• Uses a computer information system and up-to-date data
• Considers the factors of response difficulty and intervention approach (maintenance or
intensive/extended)
• Has sensitivity to the acuity of symptoms and pre-determined clinical goals
• Establishes a "case-weight" for each client and a "case-weight" total for each staff
member
• Adjusts for clinical seniority and the time per week the staff member has available to
manage the clinical caseload
King et al (2004) surmise selection of caseload variables for mental health most likely
depends on the purpose for caseload management. Service efficiency as a goal differs from
that of workload equity and will result in the selection of different caseload variables.
Speech-Language Pathology
Caseload size is reported to be of concern to speech-language pathologists (SLP’s) in a
number of countries (Cirrin, Biehl, Estomin, and Schraeder, 2003; van der Gaag, 1996;
Canadian Association of Speech-Language Pathologists and Audiologists (CASLPA), 2003).
This concern is supported by data from the American Speech-Language-Hearing Association
that suggest that client communication outcomes in schools appear to be influenced by
caseload size. (Cirrin et al, 2003).
Cirrin et al. (2003) suggest that, traditionally, workload has been viewed as being almost
exclusively synonymous with caseload. They define caseload as “the number of clients being
served either through direct or indirect service delivery options”. Alternately, they define
workload as “all activities required and performed related to provision of client services”.
Hence, workload includes face-to-face direct services to clients, as well as many other
activities necessary to support programs, implement best practices and ensure compliance
with legislative and professional standards. It follows then that any increase in caseload also
increases the overall workload.
A common theme in the literature is the need to recognize the factors that affect the workload
of SLP’s. A list of these factors described by three authors is included in Table 2.
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Table 2: Factors Affecting Workload of Speech-Language Pathologists
American Speech-Hearing Canadian Association of Speech Pathology Australia
Language Association Speech-Language
Principles of Practice
Guidelines for SLP’s in Pathologists and Audiologists
Schools Caseload Guidelines Survey (Speech Pathology Australia,
(Cirrin et al., 2003) (CASLPA, 2003) 2001)
• Caseload: The number of • Delivery models • Responsible use of client
clients serviced and public money.
• Client disorder
• Government mandated • Client outcomes and
• Severity
requirements evidence-based practice
• Work Setting data
• Student factors: Includes the
expanding range and • Client satisfaction with the
severity of disabilities service
• State/local regulations: • Client health and well-being
Includes rules for eligibility
• Ability to meet Professional
and discharge criteria
Standards of Practice
• School Policies and
• Staff satisfaction, health and
expectations: Includes
well-being
travel, paperwork, third-party
billing and data collection • Staff supervision levels
• Professional influences: • Access to professional
Includes scope of practice development
• State certification • Time for planning and
requirements: Includes preparation
requirements for continuing
education • Human resource
maintenance (i.e.,
• State and local budgets: absenteeism and turnover)
Affect allocation of
resources such as number • Length of working day
of personnel available
• Unfunded mandates: Such
as requirements to “locate,
identify and serve all
children with disabilities”
without the resources to
respond
Service delivery models are seen by some as a key strategy used by SLP’s in managing
caseloads (van der Gaag, 1996; American Speech-Language-Hearing Association, 1993).
CASLP (2003) describes the following examples of service delivery models:
• direct service to one client,
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• consultation (therapist determines intervention targets, procedures and contexts, but
relied on another agent to carry out the program);
• direct service in groups;
• collaborative model (therapist works with teacher, parent, volunteer or other
personnel).
Interestingly, Cirrin et al. (2003) noted that large caseloads in the school system have had the
effect of limiting SLP’s available service delivery options to providing interventions primarily in
groups, rather than individually, regardless of individual need.
Pertile and Page (2004) describe how, in 1992 as a result of increasing demands and waiting
lists on their service in Melbourne Australia, they searched the literature for alternative
service models. They observed that all models had benefits and limitations, but each in
isolation failed to solve their problems. They concluded that what was needed was a means
of integrating the individual models to create a complete model of service delivery. As a
result, they developed an integrated service delivery system known as Maroondah Approach
to Clinical Services (MACS). One key premise of this approach is that responsibility to the
clients starts from the receipt of the referral. The approach involves cycles of treatment that
tie all models of service delivery together. Their system allows fluid movement of clients from
one form of therapy to another without waiting lists. MACS workshops have been available in
Australia since 1998 and, since then, over 200 speech pathologists, occupational therapists,
physiotherapists, case managers and psychologists have taken the training. MACS
workshops have also been recently given in the United Kingdom.
Another approach to caseload management is described by Cirren et al. (2003) as a
workload analysis approach to set appropriate caseload standards for SLP’s working in
schools in the United States. This approach involves documentation of all of the workload
activities that must be done to meet client individual needs, ensure compliance with
education agency mandates, and implement best practices. The time it takes to perform
these activities can be compared with the time available. The author suggests that this
process can help SLP’s collect and organize their own workload data to share with
administrators and decision makers.
The Canadian Association for Speech-Language Pathologists and Audiologists (CASLPA,
2003) recently undertook a survey of its members to determine average caseloads in various
settings for clients of various ages. The intent of the survey was to assist the Board in
developing caseload guidelines for the profession. The results of the study indicated that
there was a need for guidelines and that the majority of SLP’s are currently servicing many
more clients that they would recommend as ideal. As a result many SLP’s are frustrated
because they are unable to provide an adequate level of service due to workload.
In summary, it appears that for SLP’s, caseload management is seen as an important issue
in a number of countries. Key considerations in caseload management for this profession
seem to be: the need to capture workload, not just caseload; recognition of the factors that
influence workload and caseload; and recognition of the diversity of service delivery models
in use.
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Physiotherapy
Over the past 30 years various approaches have been described as a means of managing
physiotherapy caseloads. Of note are two quite different approaches to caseload
management that have been reported in Canada and the United Kingdom (UK).
Physiotherapy caseload standards were first developed in Canada in 1975 and were based
on the Management Information Systems (MIS) Guidelines2 in place at the time. The purpose
of these standards was to provide an efficient statistical tool that could be used in the
management of physiotherapy departments. Calder and Jarvis (1986) conducted an
evaluation of these standards. The results of their evaluation indicated the following:
• Current output measures related primarily to the degree of therapeutic activity and the
number of patients contacted. Ideally, an output measure should measure the change
in a patient’s health status. They noted however that this type of measure was beyond
the “state of the art” at the time.
• Due to variations in practice, caseload indicators should be seen as guidelines or
norms rather than absolute standards. These guidelines should serve to highlight
areas of activity that should be further examined.
• Factors that are outside the direct management control of the physiotherapy
department, but have an impact on the caseload achievable, also need to be
considered. The results of their work attempted to “control” for these factors by
identifying seven different hospital types (based on the type of care provided) for five
hospital size groupings (sized according to the number of beds).
• Based on a retrospective study of the data from 661 hospitals across Canada , they
developed recommended caseload guidelines according to hospital type and size for
three different indicators:
o Number of attendances per physiotherapy department paid hour
o Number of attendances per physiotherapist paid hour
o Weighted units per physiotherapy department paid hour
Christie (1999) describes the next development related to caseload guidelines for
physiotherapy in Canada. She notes the caseload guidelines proposed in the 1980’s were
too general and therefore not helpful in determining caseloads in specific program areas. Her
research involved a five-phase project using both retrospective and prospective data
collection using the MIS Guidelines. Based on the data collected, mean caseloads were
developed for various department programs (i.e. respiratory surgical, cardiac medical, acute
neurological, etc.). The resulting guidelines provide an expected caseload range for the
number of patients per day per full-time therapist by individual patient programs. As results of
this work, the following “lessons learned” are described:
2
The Management Information Systems (MIS) Guidelines are a set of national standards for gathering and processing data
and reporting financial and statistical data on the day-to day operations of a health service organization (CIHI, 2005).
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• Caseload expectations tended to be significantly higher than the reality
• The variety in caseload ranges for different programs confirms and validates the need
for different staffing levels on different programs
• It is important that caseload guidelines remain fluid as any change in facility structure
(physical or organizational) has the potential to affect caseload manageability.
Interestingly, over the same time period, quite a different approach to caseload management
was taken in the UK. Williams (1986) states that “there are serious problems in attempting to
quantify the work of clinical professions like physiotherapy as there is no agreement on what
the performance measures should be”. She proposes that part of the problem is a lack of
nationally agreed upon definitions as to what constitutes a “case”, “caseload” or “workload” in
a physiotherapy service. She suggests that previous attempts to produce caseload
measures have assumed that the profession had a technician type role and could therefore
be measured by counting the number of patient attendances or treatments. She further
indicates that it is well recognized that this assumption is wrong. She recognized the need
for an approach that acknowledges all aspects of the professional tasks and which can be
used as a basis for developing workload, performance, manpower and costing measures.
The approach used to develop an agreed upon model involved three participatory workshops
with 180 senior physiotherapy managers participating.
As a result of these workshops, a workload model was developed for physiotherapy in the UK
that is based on four key definitions (Williams, 1986):
• Potential Caseload: A defined population which is directly monitored from which the
Current Caseload is derived and for which the physiotherapist is responsible in terms
of advice and the teaching of care-givers.
• Current Caseload: Those patients who have been assessed, have entered an episode
of care and are not yet discharged.
• Daily Caseload: Patients from the Current Caseload dealt with on one day.
• Total Workload: Within this boundary is the total workload of a physiotherapist. It
includes all that is contained within the job description and implied in the professional
role.
Williams indicates that the next step in this work is to use the model to develop and quantify
descriptive profiles of professional workloads in each of the clinical specialty fields in
physiotherapy and attribute costs. A further publication by Williams provided by the
Chartered Society of Physiotherapy provides calculations to assist in defining staffing levels
in physiotherapy services (Williams, year unknown).
More recent work from the UK by Ball (2001) uses the model developed by Williams and
provides recommendations for calculating physiotherapy staffing for General Physician
referred musculoskeletal outpatient services using a “population-based” approach. The
report outlines calculations that ultimately identify the number of qualified staff required to
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deal with the demand, based on the percentage of the population that would be referred to
physiotherapy for musculoskeletal conditions.
In summary, it appears that two different approaches to caseload management are described
in the physiotherapy literature. One approach sets caseload standards based on averages
for specific indicators that reflect the actual workload being done. The other takes more of a
“population-based approach” and seeks to understand and quantify workload (and hence
human resource requirements) as related to the needs of a specific population.
Occupational Therapy
Throughout the 1970’s, occupational therapists in Canada participated in the design and
implementation of workload measurement in collaboration with other professions and with
profession-specific working groups. The initial system, which recorded direct care, was then
expanded to encompass a wider range of specific and measurable activities. In the 1980’s,
workload management was reported to focus on productivity (Campbell, 1980; Wright, 1983).
In fact, in the early stages of development, the profession was somewhat skeptical of
workload measurement given that:
o Workload is more of an indication of efficiency not quality.
o The information needed to be understood and carefully applied.
o The system was subject to local variability and difficult to compare across settings.
o The system initially recorded only direct care delivery.
Wright (1983) identifies increasing external demands being placed on occupational therapy
services for cost-effectiveness and acceptable productivity levels. By the early eighties,
service managers also recognized that increased time was required to meet indirect patient
care and non-clinical responsibilities. An improved data management system was needed to
respond to this changing practice environment and to identify actual workloads, intervention
outcomes, program/service demands, and disease groups. Wright further reports that
improved data requirements included:
o Units of therapy related to diagnosis
o Units of direct therapy specific to measure volume and productivity against qualified/
paid hours
It was hoped that the additional information would lead to improved service planning, service
projections, staff scheduling, caseload standards, and monitoring of productivity. Data
retrieval and analysis was facilitated by computerized systems while data recording became
strictly a professional responsibility.
Over the last decade, occupational therapy literature has strongly suggested that caseload,
workload and staffing models can assist professional efforts to evaluate and better organize
services (Cockerill et al, 1994; Fortune and Ryan, 1996; Hollis and Kinsella, 1994). Several
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reported that caseload management frameworks and workload models were developed to
adapt to changing circumstances at a local level. Three models are described from the
literature reviewed, each illustrating a slightly different approach.
Fortune and Ryan (1996) describe a Caseload Management System for Community
Occupational Therapists. The authors acknowledge that clinical responsibilities include
caseload and non-caseload related activities. The model proposes clinical reasoning as
integral to caseload management and strives to achieve quality case interventions. A
secondary benefit is identified as addressing the quantity of cases. Individual therapists,
using broad guidelines, categorize each case according to the level of complexity ~ simple
(quick), simple (long) or complex.
• Simple (quick): reasoning is procedural; decisions can be made using basic or
standard protocols; situation is familiar to the therapist from previous experience; case
requires limited time
• Simple (long): reasoning is procedural; decisions can be made using basic or
standard protocols; situation is familiar to the therapist from previous experience; case
may require time but is not difficult;
• Complex: reasoning is not procedural; situation demands a highly individualized
approach; clinical reasoning is creative, imaginative and intuitive; planning,
intervention and documentation is time-consuming; previous experience assists with
effective monitoring of cases.
This categorization leads to the assignment of a numerical weighting for each case. At the
same time, a caseload allowance is established for each therapist recognizing case
complexity, level of therapist experience and mix of caseload and other professional
responsibilities. Individual caseloads are finally determined through professional judgement
and negotiation. While attempting to improve services, there is a desire to use expertise
more efficiently and ensure that complex cases are clearly identified.
In the mid-nineties in the UK, workload measurement data was being analyzed to assist with
the determination of caseload and staffing levels in occupational therapy. Hollis and Kinsella
(1994) reported a Manpower Measurement Model. The authors caution that caseload
decisions should be based on workload measurement data in conjunction with other service
measures and professional judgement. They describe a six-step model:
1. Determine the care groups receiving occupational therapy.
2. Calculate the actual staff worked-hours per episode of care.
3. Determine the total treatment time per episode of care for each care group.
4. Calculate the total clinical time available per year in each care group with current level
of assigned staffing.
5. Calculate the total number of episodes per year is each care group and numbers of
clients to be seen.
6. Determine the required staffing level considering competence and experience, clinical
time available and total episodes of care per year.
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This model goes beyond caseload to link with the need to identify staffing shortfalls, define
staffing needs and predict staffing requirements. However, it is suggested that the model is
intended for application in a local context, not at a system level.
More recently, the College of Occupational Therapists have been developing the Workload
Weighting –Essex Model (College of Occupational Therapists, Briefing 2004). Under this
model, the caseload allocation for an occupational therapist is based on the premise that
each case demands approximately four hours of a practitioner’s time over a four week period
translating into “37 active cases for every 37 hours worked”.
Under the Essex Model, the caseload allocation process is scheduled to cover a four-week
block. The supervisor meets with each staff member for a workload weighting supervision
session the week previous to the caseload allocation date. These sessions are booked in
advance for the entire year. In preparation, each therapist completes a prescribed workload
weighting form retrospectively over the four-week period. The form captures the number of
hours spent on activities over and above the active caseload. This information allows the
practitioner to justify the caseload allocation and negotiate the new caseload allocation for the
next four-week period. The system is designed to improve caseload throughput while
recognizing the actual clinical caseload and using the actual workload data.
More complete details for these occupational therapy models are presented in Appendix 3.
In summary, it appears that two different approaches to caseload management are described
in the occupational therapy literature. One approach is premised on professionals using
clinical reasoning to first determine case complexity and then establish caseload. The other
adopts a “workload measurement approach” and determines caseload based on predicted
clinical demand, required or allocated intervention time, and clinical time available.
For a better understanding of current activity in Canada, a short questionnaire (Appendix 4)
was developed and sent to a targeted list of 20 individuals provided by CAOT who had
expressed an interest in caseload assignment and management. The purpose of the
questionnaire was to obtain selected perspectives within the Canadian environment on
unpublished approaches in caseload management and the need for further work in this area.
Six replies were received, representing a 30% response rate. All respondents agreed that
there is a need for work on caseload assignment and management in Canada. Current
approaches are not always based on a specific model or framework and sometimes case
management is carried out or highly influenced by non-occupational therapy personnel. The
questionnaire results support the need for leadership from the Canadian Occupational
Therapy Association.
As health service systems undergo massive renewal and restructuring, occupational therapy
must redefine its role within the private and public service areas. More than ever before
occupational therapists are challenged to organize their services to meet population, agency
and client expectations. The expansion of service management tools could address the
growing need to predict, allocate and monitor human and financial resources (Williams et al,
2003; Cockerill et al, 1994; Boshoff, 2003).
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There is little argument that quality care and workforce management need to go hand in hand
to achieve effective and efficient health services. It seems advisable that caseload
management models in occupational therapy be applied locally considering such factors as:
workload, scope of services given resource allocation and funding, service mandate and
contract requirements, professional practice standards, and service and individual
performance expectations. Much work remains in reaching consensus on the best caseload
management tools that will be valid and reliable given the range of clinical settings and
service populations.
4.0 TOWARD BEST PRACTICE IN CASELOAD MANAGEMENT FOR OCCUPATIONAL
THERAPY IN CANADA
4.1 What can be Learned about Best Practices in Caseload Management for
Occupational Therapy in Canada?
As a result of the review of the literature and the targeted international scan undertaken for
this paper, a number of key findings about caseload management for occupational therapy in
Canada emerged. These include:
• The findings support the suggestion that caseload management is an issue in health
services and an emerging issue within occupational therapy. New management
processes and tools are now being explored and developed on the international scene.
However, there is limited progress in developing case management models with
adequate rigor to be applied at a system or local level. There is no one "right" model or
framework upon which to base a professional approach.
• Health system policy-makers at the federal and provincial levels recently issued a call to
action by introducing a 10-year plan to strengthen health services in Canada. CIHI is
charged to collect and provide valid, reliable and meaningful information to government,
service agencies and service managers. CIHI continues to invest in Management
Information Systems (MIS) and Health Human Resource (HHR) databases that are
world-class.
• In the past, caseload models for occupational therapy in Canada have tended to focus on
setting caseload guidelines based on averages for indicators that reflect the work actually
being done. The trend appears to be towards using more of a population-based
approach that seeks to understand and quantify workload (and hence human resource
requirements) in relation to the needs of a specific population.
• There is no clear direction for caseload management in occupational therapy; in fact,
more research and development is definitely required. Using workforce management and
caseload information should improve the access Canadians have to occupational therapy
services.
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• CAOT promotes best practice in the context of having procedures that are believed to
result in the most efficient provision of services while ensuring evidence-based practice,
clinical reasoning, and accountability are major contributing elements. This approach to
best practice should ensure that the organization of occupational therapy services is both
efficient and effective.
As a result of the work of this report, a number of “guiding principles” have been identified to
inform the future development of best practice in caseload management in occupational
therapy in Canada. These proposed Guiding Principles are presented in Table 3.
Table 3: Proposed Guiding Principles for Caseload Management in Occupational Therapy
• Evidence-based occupational therapy: client-centred enablement of occupation based on client
information and a critical review of relevant research, expert consensus and past experience
• Cost-Effectiveness: providing services in the most efficient and effective manner that is
consistent with acceptable professional standards for service delivery
• Accountability: enabling understanding, assessment and measurement of system performance
that facilitates continuous improvement of access, results, resource use, and service delivery itself
• Professional Leadership and Expert Judgment: Taking a leadership role in identifying clinically
relevant and caseload assignment and management models that are appropriate to occupational
therapy practice
• Comprehensiveness: recognizes the need for, and importance of, indirect as well as direct
activities in the provision of services
• Flexibility: Recognizes and reflects the diversity of delivery models in use
The development of caseload management systems must involve human resources,
workload, and caseload data. Guided by established principles, any caseload management
approach should respect several critical considerations. The approach to caseload
management for occupational therapy in Canada should be:
o Retrospective data-based: Without data, professional judgements will be based on
intuition and perception. Best practice demands much more. There is an ongoing need
for meaningful data and new caseload measurements in reliable and computerized
formats. Database systems are needed to provide accurate, reliable, timely and
accessible real-time information. Given the development of more valid and reliable
management information systems at local, provincial and federal levels, retrospective
data is now more readily available.
o Population-specific: The practice of occupational therapy engages various client
populations, each with its unique needs and challenges. The findings suggest that
retrospective data is most valid and reliable when considered in relation to clinically
relevant and appropriate client case groups. Such case groups are best identified by
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expert occupational therapists given data availability and caseload sensitivity. In
developing a caseload management approach, factors should be considered such as
population characteristics, access and demand patterns, service delivery approaches to
specific populations and population outcomes.
o Context-specific: The context of the occupational therapy service should shape the
approach to caseload management. Given the range of factors reported in the literature
to be relevant to caseload management, it is important to carefully select and quantify the
most critical factors to specific context of practice for occupational therapy. Although
several factors may be context-specific, case complexity, and service models or
approaches appear most common across reviewed professional models. Caseload
models should always consider service and client outcomes. When expected outcomes
for case groups are not met, caseload assignment processes should be re-evaluated and
re-aligned with client needs and resource priorities.
4.2 What are the Recommendations for Further Work on Caseload Management for
Occupational Therapy in Canada?
In summary, this paper has highlighted a number of issues related to caseload management
in occupational therapy, including proposed guiding principles and a suggested approach.
Based on the key findings of this inquiry, a number of recommendations for next steps are
suggested below.
1. CAOT should conduct a survey of Canadian practice settings to develop an
inventory of current caseload management practices in occupational therapy.
(Year 1)
2. CAOT should host a consensus workshop on best practice for caseload
management in occupational therapy in Canada. This initiative should include
development of a pre-workshop discussion paper with survey results, proposed
principles and guidelines, suggested case groups and caseload management
factors, and a range of approaches. (Year 2)
3. CAOT should consider commissioning specific research to develop valid and
reliable caseload management frameworks/models that are specific to major
occupational therapy case groups. (Year 2)
4. CAOT should facilitate the development of a framework that integrates evidence-
based practices to shape best practices in caseload assignment and management
in occupational therapy in Canada. Clinical reasoning and accountability are
viewed as integral to any caseload management framework. (Year 2)
5. The occupational therapy community should initiate and continue to conduct
research to evaluate the impact of caseload management on service, practitioner
and client outcomes. (Year 3)
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It appears that the need for appropriate caseload management within occupational therapy,
and other health services is widely accepted. Occupational therapists may well be prepared
to move forward with caseload management approaches that recognize clinical reasoning
and accountability as integral to the development of best practices.
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Appendix 1: Caseload Assignment and Management
Summary of Results of Environmental Scan of International Associations
in Selected Health Professions
Profession Speech and Language Pathology Physiotherapy Occupational Therapy
Country
Australia • Speech Pathology Australia is • No reply • Australia Association of Occupational
currently compiling a document Therapists does not have caseload
pertaining to workforce data, but it information available at national level.
does not include caseload data in
any details
• Have plans to perform survey to
identify specific caseload data, but
this has not yet been undertaken
• Provided “Principles of Practice”
Document that provides general
advice.
Canada • Canadian Association of Speech- • Canadian Physiotherapy • The Canadian Association of
Language Pathologists conducted Association does not have any Occupational Therapists is currently
member survey in 2003 to recent work related to preparing background paper.
determine average caseloads in caseload guidelines.
three age groups.
New • New Zealand Speech-Language • New Zealand Society of • The New Zealand Association of
Zealand Therapy Association does not Physiotherapists has not done Occupational Therapy identified two
have any specific numbers in any work on caseload waiting list and caseload management
terms of caseload guidelines guidelines. tools:
• Presently are investigating service o The Wigan Method (details
delivery and will be investigating unavailable)
caseloads. o The Maroondah Approach to
Clinical Services (M.A.C.S)
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Profession Speech and Language Pathology Physiotherapy Occupational Therapy
Country
United • The Royal College of Speech and • The Chartered Society of • The College of Occupational Therapists in
Kingdom Language Therapists had a Physiotherapy does not have the United Kingdom reported that there
project due to start in February caseload guidelines. has been very little done on caseload
2005 to look at workforce and • Provided two documents that guidelines.
caseload include guidance for • Provided briefing they have done on the
• Provided information prepared for calculating staffing levels in subject.
their management board that physiotherapy. • Have started an email network for OT’s to
identifies some of the issues for assist them in developing further tools.
consideration.
United • American Speech-Language- • The American Physical • The American Occupational Therapy
States of Hearing Association (ASHA) has Therapy Association does not Association does not have caseload
America developed information for SLP’s have any caseload guidelines guidelines and have not carried out
working in schools regarding at this time. studies on this topic either.
caseload management. • They do have results from • Indicated that it is very difficult to provide
• For SLP’s in health service, ASHA surveying members on their guidelines regarding caseload because
does not set or recommend a productivity expectations in this varies depending on the acuity of the
standard productivity level as this their work setting that is condition, type of services provided, and
is highly dependent on the setting available for members only. nature of the setting.
and patient population. • Indicated that health service
organizations, state departments of
education, or school systems may have
individual policies in this area.
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Appendix 2: Caseload Index Factors in Mental Health
Advantages and Limitations of Seven Potential Factors Used in a Caseload Index
Factor Advantages Limitations
Contact frequency • Routinely collected data • Potential to encourage over-
• measure of service • Index of time consumed by servicing
demand client • Does not take into account duration
of contact
Response difficulty • Provides an index of expected • High response difficulty does not
• measure of client need time allocation always equate to workload
and level of individual • Response difficulty may be highly
service required variable within caseload period
Intervention type • Recognizes variable time • May favour high intensity
• reflects the range of demands of different types of interventions
evidence-based intervention
interventions
Competence/seniority • Makes higher performance • Little evidence that experience or
• reflects the range of demands on those best seniority results in increased
skills and experience equipped to manage efficiency
that affect caseload • Any efficiency benefit difficult to
capacity quantify
Caseload maturity • Recognizes the increased • No basis for quantification
• considers the greater work demands associated • Fails to take into account other
burden of work required with new cases periods of increased workload
earlier rather than later
in the process
Location of clients • Allows for travelling time • Need for travel difficult to measure
• considers the • Recognizes inverse • Difficult to quantify additional
geographical relationship between services service demand associated with
distribution of client provided by case manager rurality
caseload and services available in the
community
Roles other than case • Recognizes multirole • May reduce flexibility in staff
management functioning of mental health deployment
• considers the non- staff
caseload
responsibilities
Adapted from King et al (2004, p. 457)
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Appendix 3: Caseload Management Frameworks in Occupational Therapy
Name/Location of Purpose of Framework Components of Framework Future
Framework Use/Recommendations
Caseload • To primarily ensure • Accepts clinical reasoning as core to occupational therapy • There is a need for ongoing
Management System quality case interventions as a practice-based profession and more formal
for Community with a secondary benefit • Focuses on case complexity and allows for different levels evaluation.
Occupational of addressing quantity of of therapist experience • The system was not
Therapists (Fortune & cases • Bases case-weighting on the subjective perception on the devised to apply to
Ryan, 1996) • To improve services by level of case complexity as determined by individual assistants and requires
reducing unnecessary therapists having different levels of experience more study.
• Initially developed cases, freeing time to • Categorizes cases as simple (quick), simple (long) and • It is suggested that this
in 1991 by work on complex cases complex; and assigns a numerical weighting using model allows occupational
occupational and using expertise more established guidelines to assist with determining the case therapists to reflect
therapists from the efficiently complexity critically, consider
Poplar • To assist staff • Simple (quick): reasoning is procedural; decisions complexity and deal with
Neighbourhood development can be made using basic or standard protocols; practical issues.
Team in the situation is familiar to the therapist from previous • The model facilitates
London Borough of experience; case requires limited time interacting and managing
Tower Hamlets, • Simple (long): reasoning is procedural; decisions can clients through a holistic
London, England be made using basic or standard protocols; situation approach.
is familiar to the therapist from previous experience;
case may require time but is not difficult;
• Complex: reasoning is not procedural; situation
demands a highly individualized approach; clinical
reasoning is creative, imaginative and intuitive;
planning, intervention and documentation is time
consuming; previous experience assists with effective
monitoring of cases
• Assigns the numerical weighting for each case
considering case complexity, level of therapist experience
and mix of caseload management and other professional
responsibilities
• Establishes an individual caseload allowance for each
therapist and allows the negotiation of a reasonable mix of
complex and simple cases that does not exceed the
established caseload allowance
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Name/Location of Purpose of Framework Components of Framework Future
Framework Use/Recommendations
Manpower • To have agreed upon 1. Determination of care groups receiving occupational • The user of a computer-
Measurement Model occupational therapy therapy services based system facilitates
(Hollis and Kinsella, staffing levels using staff access to more detailed
1994) input and data 2. Calculation of staff input hours per episode of care information and makes
• West Dorset • To identify staffing • Allocation of time to specific aspects in the occupational this system less time-
Community Health shortfalls, define staffing therapy process including initial review/assessment, group consuming.
NHS Trust needs and predict staffing or individual treatment, liaison and home visit • The application of
requirements • Decisions made on the level of involvement of the workload measurement
occupational therapist and or the occupational therapy data for determining
assistant based on professional standards staffing levels should be
• The determination of time allocated to an episode of care considered with other
must reflect local service circumstances and geography service measures and
Time Qualified Assistant Carried out by validated by professional
allocation OT Either staff grade judgement.
Initial • The approach in
interview/
assessment
developing the workload
Treatment: framework may be
individual or valuable to consider in
group other projects, however,
Liaison the results are intended
Home visit for local review and
Total applicable only in the
local context.
3. Determination of the total treatment time per episode of • The workload model for
care for each care group determining staffing
levels is only useful if the
4. Calculation of clinical time available per year in each care data is updated to reflect
group changing referral
patterns and service
# of hours worked Time % non- Total clinical time delivery.
per annum minus available per clinical available (hours)
leave annum time
OT
OT Assistant
5. Calculation of total episodes per year in each care group
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Name/Location of Purpose of Framework Components of Framework Future
Framework Use/Recommendations
Total clinical time Total episodes of care Total number of
available per annum patients to be seen
6. Determination of required staffing levels depending on the
total clinical time and total episodes per year in each care
group given, the following considerations:
• Clinical staffing levels exclude non-clinical time and include
all patient related activities
• Determination of clinical time available excludes annual and
statutory leaves
• The allocation of staff workload must relate to competence,
experience, ongoing training and the clinical supervision
available
• Staffing levels are intended to include, not exclude
assistance
Workload Weighting • To research and • Proposed Hypothesis: on average, a case demands • Information systems must
(College of evaluate issues of approximately four hours of a practitioner’s time during a be introduced to provide
Occupational caseload weighting and four week period. This principle translates into a caseload data in support of any
Therapists, 2004) workload management of 37 active cases for every 37 hours worked. workload weighting system.
• The "37 for 37 principle" proposes that an active case has • These systems allow
Workload Weighting: ongoing practitioner involvement and requires at least one practitioners to improve
Essex Model (1999) hour of time per week. It was recognized that more their caseload throughput
intensive cases are balanced by those cases that are less and to recognize their
• Project Group in time consuming. actual clinical caseload.
the Essex Social • The caseload allocation process was scheduled to cover a • Workload weighting
Care Occupational four-week period. The supervisor meets with each staff systems provide
Therapy Service, member for a workload weighting supervision session the practitioners with
Essex, England week previous to the caseload allocation date. Sessions information to support their
are booked in advance for the entire year. negotiations for caseload
• The workload weighting form is completed retrospectively allocations.
over the four-week period. The form captures the number • Although auditing of the
of hours spent on activities over and above the active system has occurred, more
caseload. This information allows the practitioner to justify investigation must be
the caseload allocation and negotiate the new caseload undertaken to validate and
allocation for the next four-week period. analyze clinical and non-
clinical casework.
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Appendix 4: Survey on Caseload Assignment and Management
Name:
Contact Information:
Name and Province of Employer:
In order to capture the range of respondents, we would appreciate specification of the following:
1. Please check all the practice settings that apply to your involvement with an
occupational therapy caseload or caseload assignment and management role.
General hospital
Client’s home
School system
Rehabilitation centre
Chronic care / LTC facility
Mental health facility
Paediatric centre
Private health business
Community clinic / agency
Correctional services
University
WCB
Client’s work site
Government
Other (identify) _________________
2. Please check all the areas of practice that apply to your involvement with an
occupational therapy caseload or caseload assignment and management role.
Neurological conditions
Orthopedics
CVA (stroke)
Developmental disabilities
Gerontology
Other (identify) ____________________
3. Do you have direct responsibility for caseload assignment to occupational
therapists?
Yes No
4. Is your approach to caseload assignment based on a specific model or framework?
Yes No
If yes, describe briefly.
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Based on your opinion and / or experience:
5. Is there a need for work on caseload assignment and management for occupational
therapy in Canada?
Yes No
Comment on why or why not?
If you responded No to Question 5, go to Question7. If you responded Yes to Question 5,
go to Question 6 below.
6. Identify the 2 greatest needs for work on caseload assignment and management from
the perspective of each group identified below:
a) Occupational therapists
1.
2.
b) Clients/Consumers of Occupational Therapy Services
1.
2.
c) Occupational Therapy Service Managers
1.
2.
d) Health Service Agencies
1.
2.
e) Health Service Planners
1.
2.
7. What are the 2 most important things for the Canadian Association of Occupational
Therapists to undertake to further progress on caseload assignment and
management for occupational therapy in Canada?
1.
2.
8. Identify published information or articles in the literature that you feel are informative
to the subject of caseload assignment and management in occupational therapy in
Canada.
9. General Comments
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GLOSSARY
Best Practice: A term used in business, health and education referring to procedures
that are believed to result in the most efficient provision of a product or service (CAOT,
1999)
Caseload: Refers to the number of clients being served by a health professional either
through direct or indirect service delivery options (adapted Cirrin et al, 2003). Caseload
can be further defined as follows:
• Current Caseload: Those patients who have been assessed have entered an
episode of care and are not yet discharged (Williams, 1986)
• Daily Caseload: Patients from the Current Caseload dealt with on one day
(Williams, 1986).
• Potential Caseload: A defined population which is directly monitored from which
the Current Caseload is derived and for which the professional is responsible in
terms of advice and the teaching of care-givers (Williams, 1986).
Clinical Reasoning: Refers to “the thought process that guides practice” (Rogers,
1982) and encompasses five different types, including (Mendez & Neufeld, 2004):
• Procedural reasoning
• Interactive reasoning
• Conditional reasoning
• Narrative reasoning
• Pragmatic reasoning
Management Information Systems (MIS) Guidelines: are a set of national standards
in Canada for gathering and processing data and reporting financial and statistical data
on the day-to-day operations of a health service organization (CIHI, 2005).
Workload: Refers to all activities required and performed by a health professional
related to provision of client services. Workload includes face-to-face direct services to
clients, as well as many other activities necessary to support programs, implement best
practices and ensure compliance with legislative and professional standards (adapted
Cirrin et al, 2003). This concept is also described as:
• Total Workload: Includes all that is contained within the job description and
implied in the professional role (Williams, 1986).
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