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Managing Continuity Through Case Coordination


Community case co-ordination assists elderly clients requiring community-based health care to receive services and reduce or delay the use of acute care and long-term care. Case co-ordination typically involves assessment of client needs, care plan development and implementation, monitoring service provision, and reassessment. Despite the general framework of these activities, perceptions of case co-ordination often differ considerably, particularly in regard to the nature and frequency of co-ordination services. In addition, the amount of co-ordination is not always adequately linked to the client's level of need. The purpose of this project was to develop guidelines for community case co-ordination that were linked directly to the client's level of need. In order to increase the usefulness of the guidelines, the goal was to base these guidelines on actual practice as opposed to preferred practice.

Back (L-R): Michelle Bourgault, Tandy White, Mark Sagan, Cecily Bierlein, Heather Hadjistavropoulos
Front (L-R): Sue Neville, Linda Wacker, Dawn McNeil
Missing: Allisson Quine, Gretta Lynn Ell

Data were collected on clients receiving community case co-ordinated services. The clients were older than 65 and entered the study at their initial referral to case co-ordination. At that time, their risk of being institutionalized was determined. Case co-ordinators tracked the time they spent co-ordinating services for each client in the study over six months. After examining actual case co-ordination practice as a function of client's level of risk, guidelines were drafted by an expert panel of case co-ordinators, decision makers, and researchers. A series of focus groups including clients, service providers, and decision makers evaluated the guidelines. A brief tracking form based on the draft guidelines was piloted in May and June of 2003, and feedback was used to form the final guidelines.


This study provided objective data for use in better understanding case co-ordination of community health services for elderly, community-dwelling clients. Guidelines can be used to reduce inconsistency in case co-ordination delivery and to improve accountability. As well, the guidelines increase awareness of practices for those not directly involved in case co-ordination. Decision makers can use this objective data in program planning and to gain a greater understanding of resources needed for case co-ordination. The guidelines can assist with the education and training of new case co-ordinators by establishing benchmarks to guide practice. The guidelines may also be used as a quality measure, to ensure fair and consistent case co-ordination, both on an individual and aggregate level. The specific times and ranges developed will likely vary by region as well as by the case co-ordination model employed (e.g., brokerage versus care-based), but the method and format of developing guidelines could be applied to any region or other client populations.

Project Results

This project resulted in the development of case co-ordination guidelines that specify ranges of co-ordination time and frequency of contact with elderly clients based on clients' risk of being placed in an institution (low, some, high). Data analysis revealed that the majority of new referrals to case co-ordination exhibit low or some risk of institutionalization. However, those clients exhibiting higher risk used more case co-ordination time and more homecare services, on average. The data gathered on case co-ordination time revealed that the majority of case co-ordination occurs in the first month for assessment, plan development, and plan implementation activities, and then tapers off into a monitoring function.

Participants in this study said guidelines should have a wide range of case co-ordination times to allow for professional judgement and for individual client variability. Also, case co-ordinators requested lengthening the amount of time between scheduled full reassessments for low-need clients (e.g., three years instead of one year), as reassessing low-need clients annually was felt to be inefficient. To ensure clients were appropriately monitored for changes in their health or support status, routine service reviews were built into the guidelines at three months for new clients and one year thereafter. In addition, the guidelines specify that when clients experience significant changes in functioning, service use, or social support, the co-ordinator initiates a service review or a full reassessment to ensure clients' changed needs are fully understood and appropriately met.

Identified Barriers to Success and Recommendations

Analysis of information collected through focus groups demonstrated that potential barriers to implementation of guidelines included fear of rigid application, a disconnection between co-ordinators and service providers, need for staff buy-in, increased paperwork, and high caseload sizes. To address these concerns, the guidelines were emphasized as a supportive tool with scheduled service reviews to foster greater communication among co-ordinators and service providers. Staff buy-in was achieved through inclusion of staff in the development process, a pilot implementation, and continuous feedback. Paperwork was kept to a minimum through the addition of only one new activity tracking form and one service provider form. High caseload sizes were taken into consideration by tracking only a small portion of clients at any given time. Parameters for how urgently assessments should be done were also added, as clients identified this as an important aspect.

In summary, we recommended that guidelines for case co-ordination are necessary to ensure consistency and quality of service delivery. Guidelines must be based on actual practices and available resources, not preferred arbitrary standards. Guidelines must be flexible to allow for variation within need levels, but not be as wide in range as to be meaningless in setting expectations for service delivery. Development of effective guidelines also requires the involvement of case co-ordinators, clients, service providers, and decision makers. Finally, by gathering information about case co-ordination, a better understanding and appreciation of the nature and importance of case co-ordination is achieved by clients, service providers, and decision makers.





Project Identifier



Regina Qu'Appelle Health Region
Saskatchewan Economic and Development, Innovation and Science Fund

Principal Investigator

Heather Hadjistavropoulos, Ph.D., R.D. Psych.

Associate Professor
Department of Psychology
University of Regina
Regina, SK S4S 0A2
(306) 585-5133

Fax: 1 (306) 585-4827

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