Primary Care Health Services
7227 Hamilton Avenue
Pittsburgh, Pennsylvania 15208
Contact: Jennifer Williams, R.N.
Phone: (412) 244-3529
Key words: specialized case management;
level of functioning; utilization of
primary health care and social services;
housing status; medication compliance
The purpose of this study was to measure
how successful intensive case management
was in helping homeless clients with complex
medical and psychosocial needs to have
an improved level of functioning as manifested
by their utilization of primary health
care services and social services; housing
status; and medication compliance.
METHODS
All clients at HCH clinics received a
comprehensive medicalpsychosocial assessment.
Intensive Nurse Case Management services
were made available to those meeting established
selection criteria. The study population
consisted of 40 sheltered males (ages
18-75) from 4 emergency shelters with
weekly on-site HCH clinics who were enrolled
in case management services between November
1996 and July 1997. All participants had
a chronic health condition, excluding
severe mental health and/or substance
abuse disorders. A comparison group (n=44)
was selected through random interviews
for matching purposes.
The Nurse Case Management Model consisted
of an aggressive proactive approach to
meeting client needs. Based on assessment,
a Problem List and an Individual Service
Plan (ISP) was developed and implemented
with the clients and relevant health team
members input. Immediate health-related
needs were met through the HCH clinic
and continued there until integration
with a primary care provider was successful.
Participants were educated on health and
social service options and the importance
of a primary care provider. Referrals
to appropriate providers and agencies
were made with outcomes carefully monitored
through consistent tracking and documented
on a referral flow sheet.
Housing status was collected at case management
intake and termination and compared to
control group responses from a questionnaire.
Initial housing status on all participants
in the intervention group and the comparison
group was an emergency homeless shelter.
Medication compliance for those participating
in the case management intervention group
was determined using a tracking record
with a coding system that defined compliance
or noncompliance.
Comparison group data was measured through
an individuals response to specific questions
related to availability and ability to
take medications on a regular basis by
answering Always, Sometimes, Rarely, or
Never. Only responses that indicated Always
were deemed compliant.
Utilization of primary health care providers
and social service agencies was collected
throughout case management intervention
and correlated with the number of weeks
of participation in case management activities.
Chi square and Fishers exact test were
used to determine statistical significance
of the above mentioned relationships.
Housing status changed significantly from
case management intake to case management
exit. Of the 40 case managed clients,
42.5 percent maintained or achieved a
more stable, supportive, autonomous residence;
12.5 percent remained in emergency shelter;
and 15.0 percent regressed to a street
status or a doubled-up status. Of the
case managed clients (30 percent) that
could not be assessed for housing status
at the studys termination, 91.7 percent
of this group were case managed for less
than 12 weeks. While at intake the housing
status was similar for both the case managed
and control groups, by the conclusion
of the study the case managed group showed
significant improvement in housing status.
Seventy percent of all case managed clients
utilized a primary care facility throughout
case management. A significant increase
in primary care utilization was displayed
if a client was case managed for a minimum
of 4 weeks. Medication compliance with
the case managed group at intake was not
significantly different from the case
managed group at exit.
The social services most utilized by all
case managed clients were mental health
services (60.0 percent of clients); housing
services (55.0 percent of clients); and
drug and alcohol services (40.0 percent
of clients). There was a significantly
greater number of case managed clients
who had utilized social services at exit
(90.0 percent) than those in the control
group (34.1 percent).
Significant improvements occurred with
the case management group from intake
to exit with regard to primary care utilization;
housing status; and social service utilization.
While the results of this study support
the assertion that intensive case management
helps to improve the level of functioning
of clients who receive this service, the
study raises questions that warrant further
examination. Due to time and budgetary
constraints, the sample size was limited,
allowing for minimal generalization of
the results.
Since this sample was limited to homeless
men, some future studies should also include
females and adolescents. Although some
of the clients in this study utilized
mental health services, none of the participants
had serious chronic mental health or substance
abuse problems; this is, therefore, another
area of study that should be explored.
Definitions of case management sometimes
vary. Intensive case management often
involves a great deal of time, expertise,
documentation, and supportive services.
Differences in case management could play
an important role in client integration
and reintegration into health care systems
as well as in improved physical and social
functioning. Some of the factors that
appeared to make this case management
model as effective as it was included
the fact that the case manager was a nurse
who possessed experience with homeless
clients; good interviewing skills; maintained
a good established rapport with shelter
staff; and had a great deal of familiarity
with the managed care network in the area,
particularly as it related to Medicaid
managed care.
Intensive case management from a health-focused
perspective was concluded to be significantly
effective in helping to increase clients
level of functioning. At the conclusion
of the study, significant improvements
were observed in the areas of primary
care utilization; social service utilization;
and housing status.
