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Caseload management in learning disabilities

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VOL: 98, ISSUE: 14, PAGE NO: 38

Margaret Todd, MBA, BA, RGN, RMN, RNLD, DipN, is senior lecturer, andAnna Caffrey, BSc, is research assistant, department of health and social care, University of Hertfordshire, Hatfield

Community learning disability teams (CLDTs) face growing pressures to manage increasing caseloads with available resources. The contributing factors include an ageing population (Fernandez, 2000), greater life expectancy and age-related problems in people with learning disabilities, and consequently more elderly carers who are in need of support.


Community learning disability teams (CLDTs) face growing pressures to manage increasing caseloads with available resources. The contributing factors include an ageing population (Fernandez, 2000), greater life expectancy and age-related problems in people with learning disabilities, and consequently more elderly carers who are in need of support.



Advances in treatment and technology mean that more people with complex disabilities survive into adulthood, while improved diagnosis of conditions such as autism, including Asperger’s syndrome, increases the need for specialist help. In addition, service users’ and carers’ expectations are rising. The result is that the already high number of referrals is increasing and waiting lists are getting longer. With this in mind, one CLDT decided to initiate an action research project on effective and accurate caseload management.



Aims and objectives
The main aim was to design a tool that could be used to measure client needs and help team members to manage their caseloads. This was broken down into four key components (Box 1). Service managers, practitioners and academics agreed on these aims.



Participatory action research was the chosen method for the project, with monthly focus group meetings attended by nominated representatives from each team and discipline. An action research approach ensures that practitioners have ownership of the completed tools and systems, and are therefore more likely to use them. It also created an opportunity for wide participation in the project.



Measuring caseloads
Although little research has been done on managing caseloads in multidisciplinary and CLDTs, the literature identified two methods of analysing caseloads. These are activity analysis, which involves measuring the standard care time for specific procedures, such as taking blood pressure; and dependency analysis, where the average care time is recorded for each client category.



Dependency analysis was chosen because activity analysis does not enable people to account for multitasking and the different working practices of individual disciplines make it unsuitable for multidisciplinary groups. Specific client categories, based on dependency, were devised.



A caseload management tool was developed by the focus group. It is not meant to be a checklist and was designed to acknowledge and account for the impact of various factors, such as the complexity and nature of work with each client, on professionals’ time. The tool is divided into four main sections (Box 2). Each section and subsection is scored on a 0-4 scale, with the highest score indicating the longest care-time requirement.



After designing a system to measure caseloads, it was necessary to determine acceptable numbers for each professional group. For example, the caseloads of all nurses on a particular grade were added up, with the average considered an acceptable figure. This was discussed and agreed with the nurses, and was done for each grade.



Prioritising referrals
Since the reorganisation of national health and social services in 1991 there has been pressure to prioritise referrals to community mental health services (Job, 1999), but little in the literature relates to CLDTs. Prioritising referrals in this field relies on finding a way to compare degrees of disability in individual cases. However, the concept of setting formal priorities in health and social care, particularly to cope with a paucity of resources, both in terms of finances and staffing, has not been formally touched on in community learning disability services (Callahan, 1994).



Measuring client needs
Clients with severe mental illness are given priority in mental health services, but there are no such guidelines for people with learning disabilities. To determine the priority of one client over another, it is necessary to compare each client’s degree of need. In medicine, it may be appropriate to prioritise need according to diagnosis as outcomes and interventions can be predicted, but this is a more complex issue when working with clients with learning disabilities in the community.



A literature search did not reveal any work on prioritising clients with learning disabilities, so it was felt that examining what had been done in community mental health teams might provide a framework on which to build. An unpublished survey carried out in the south-west region revealed that these teams prioritised clients according a number of factors. The following were identified as relevant to CLDTs:



- Risk of deliberate harm to self or others;



- Risk of child abuse and/or physical abuse;



- Lack of family/carer support;



- Legal requirements;



- Known to reach crisis easily or repeatedly;



- Severe adverse life events.



The teams have found the prioritisation tool extremely useful but the discharge-planning tool is still being evaluated, so this work is ongoing. After developing a tool to measure and standardise caseloads, and after consultation with the relevant professionals, the focus group decided that these factors could be a good starting point for the next stage of its work with clients with learning disabilities.



Subsequent to the initial work described in this article, the focus group decided to develop two more tools to aid caseload management. These relate to prioritising referrals and discharge planning.



The completed tool to help prioritise referrals has been passed on to managers in the trust and is in the process of being implemented. Its use will be monitored and, once established with teams, it will provide useful statistical information on issues such as how referrals are managed and their impact on caseloads, which can then be evaluated.



The discharge-planning tool is still being evaluated so this work is ongoing. The outcome of the research should be disseminated throughout the original trust but, as it has now merged with two others, the scope for use of the tools throughout the wider trust has not been determined. The trust is seeking further funding to take the research forward but the outcome of its bid is not yet known.

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