Problem identification and care plan responses in a home and community-based services program

This study examines how case managers identify and respond to home care client needs through chart reviews of 169 randomly selected clients in a home care program. Algorithms from the Minimum Data Set for Home Care to identify client needs were applied to the existing data to determine whether a potential problem existed in any of 23 broad categories of need. The authors also determine whether these problems were noted by the case manager and identify various types of responses made in the care plan. Compared to the range of problems identified with the algorithms, case managers were more likely to note functional and mental health problems than clinical health problems. Some problem categories (e.g., functional performance and brittle support) almost always received a response, whereas others (e.g., sensory performance, mental health, and some clinical problems) remained unmet even when the problem was noted. Implications for training case managers and resource development in the community are discussed.