Using the "Seven A's" assessment tool for developing competency in case management

Article (PDF Available)inThe Journal of the New York State Nurses' Association 35(1):26-31 · April 2004with28 Reads
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Abstract
In the latter part of the 20th century, healthcare reform sparked a transition in the nursing curriculum from acute care to primary and secondary care. Faculty responded to this challenge by redesigning curricula in creative ways. The transitional curriculum introduced community clinical experiences designed to challenge students to practice in diverse, nontraditional sites and in more independent ways. Such practice requires the nurse to function as designer, coordinator, and manager of patient care in addition to the traditional provider role. Additionally, the transitional curricula emphasized the roles of communicator, educator, facilitator, listener, and advocate to a greater degree. For students to achieve competence in the above roles, the curriculum must include learning activities that allow them to practice as case managers in the community. This paper presents the "Seven A's" as a framework for students to gain an understanding of and engage in the role and process of case management in the community.
26 Journal of the New York State Nurses Association, Spring/Summer 2004
Using the “Seven A’s” Assessment Tool for Developing Competency in Case Management
Using the “Seven A’s” Assessment Tool
for Developing Competency in
Case Management
Louise P. Gallagher, EdD, RN, FNP
Marie Truglio-Londrigan, PhD, RN, GNP
Abstract
Several factors influenced healthcare reform
in the 1990s. These included concerns
regarding cost containment, the need for
consumer involvement, the importance of
access to care, shifts in demographics, and
disease burdens (Pew Health Professions
Commission, 1991). The healthcare
environment no longer supported lengthy
hospital stays. In response to these concerns,
there was a need for nursing education to
address these factors and provide healthcare
professionals with a new skill set.
The Pew Health Professions Commission
(1991) recommended curriculum revisions in
health professions education. This report
proposed a major focus on health and primary
health care delivery; increased emphasis on
health promotion and maintenance; inclusion
of individuals, families, and communities in
decision making; a commitment to serving
underserved populations; and an
interdisciplinary approach, with a focus on the
role community plays in the health of
individuals and families.
A call to action for nursing
In the early 1990s, the American Nurses
Association (ANA) (1991) and the National
League for Nursing (1993) presented a vision
of nursing education in which a community-
based curriculum would become the norm.
In the intervening years, many nursing
programs have broadened their focus to
include principles of community practice
with emphasis on health promotion and
disease prevention.
Northeastern University was one of the
earliest advocates for such curriculum change
(Matteson, 1995). This model emphasized
teaching nursing in the neighborhoods and
specified curriculum changes that would
emphasize health rather than disease as the
primary concern of nursing, with
concentrations on promoting, maintaining,
and restoring health. As programs adopted
these curriculum changes, students were
introduced to the community outside the
traditional acute care setting.
Louise P. Gallagher is a professor at the Pace University Lienhard School of Nursing in Pleasantville, N.Y. and also has a faculty practice at the
Westchester Visiting Nurse Service, Westchester County, N.Y. Marie Truglio-Londrigan is an associate professor at the Pace University Lienhard
School of Nursing and serves as co-director of the school’s Institute for Healthy Aging and chairperson of the Graduate Department.
In the latter part of the 20th century, healthcare reform sparked a transition in the nursing curriculum from acute care to
primary and secondary care. Faculty responded to this challenge by redesigning curricula in creative ways. The transitional
curriculum introduced community clinical experiences designed to challenge students to practice in diverse, nontraditional
sites and in more independent ways. Such practice requires the nurse to function as designer, coordinator, and manager of
patient care in addition to the traditional provider role. Additionally, the transitional curricula emphasized the roles of
communicator, educator, facilitator, listener, and advocate to a greater degree. For students to achieve competence in the
above roles, the curriculum must include learning activities that allow them to practice as case managers in the community.
This paper presents the “Seven A’s” as a framework for students to gain an understanding of and engage in the role and process
of case management in the community.
Journal of the New York State Nurses Association, Spring/Summer 2004 27
Transitions in nursing curricula
These curriculum changes eventually became evident in nursing
programs across the country. Learning experiences in nontraditional
clinical settings was a major curriculum change adopted by many
schools. These nontraditional settings included homeless shelters, food
kitchens, can redemption centers, housing complexes, and day care
centers.
Community assessments and community diagnoses allowed for the
development, implementation, and evaluation of complex intervention
strategies with a focus on the care of individuals, families, and populations.
This community focus also introduced students to a broader level of
interdisciplinary work, along with a basic understanding of partnerships
and coalition building. A key component of partnerships was the ultimate
understanding of the meaning of working with people in their own home
community rather then working with people in the traditional hospital-
based environment. Another major focus was working with community
organizations for the purpose of coalition building.
It became clear, however, that the role of the professional nurse and
the skills required for efficient and effective practice were more extensive
in the community setting. Too often, faculty assumed that it would be
sufficient to place students in a community setting and allow them to
practice the technical skills traditionally applied in the acute care setting
(Meservey & Zungolo, 1995). Although these skills are important and
must be applied in all settings, there are other
roles (advocate, negotiator, relationship developer,
advisor, compromiser, coordinator, facilitator,
politician, listener, teacher, counselor, and
spokesperson) that are particularly important in
the community setting.
The American Association of Colleges of
Nursing (1998) has developed The Essentials of
Baccalaureate Education of Professional Nursing
Practice, which speaks to today’s complex system
of care and addresses the need to revise
baccalaureate nursing curricula. Specifically, it
outlines the need for educational components such
as: “liberal education, professional values, core
competencies, core knowledge, and role
development” (p. 6). It also discusses role
development, including healthcare designer, coordinator, and manager.
The baccalaureate curriculum needs to address each of the roles to ensure
that students are competent in their application. Nowhere is this more
critical than in the community-based practice setting.
The role of case manager
The role of case manager in the community has been the method of
care practiced for more than 100 years (Knollmueller, 1989). The ANA
(1991) defines case management as “...a healthcare delivery process
whose goals are to provide quality healthcare, decrease fragmentation,
enhance the client’s quality of life, and contain costs” (p. 6). Its model
includes assessing the client’s health status, serving as a conduit and a
broker to connect clients with the appropriate community services,
coordinating existing services to which the client is referred, monitoring
the client’s use of the service, and determining the client’s satisfaction
with the service.
Netting and Williams (1999) viewed case management as a way to
advocate for clients who need to negotiate the complex healthcare
system and to allocate resources to contain the cost of care. The Case
Management Society of America has defined case management as “a
collaborative process which assesses, plans, implements, coordinates,
monitors, and evaluates options and services to meet an individual’s
health needs through communication and available resources to
promote quality, cost-effective outcomes” (Case Management Society
of America, 1994, p. 60).
Positive outcomes of case management
Case management facilitates positive outcomes. Burns, Lamb, and
Wholey (1996) noted that homebound elderly who received case
management services experienced fewer hospitalizations and lower
healthcare costs. A pilot study conducted by Noel and Vogel (2000)
suggested similar results, indicating that nurse case management
combined with telemedicine reduced hospitalization and resource costs
to homebound elderly.
Prevention of disability and institutionalization
(Stuck et al., 1995) and satisfaction with the
program of care (Cummings et al., 1990) has been
documented. Shapiro and Taylor (2002) noted that
community-based case management as an
intervention for older adults was positively
associated with the older adults’ subjective well-
being and negatively associated with permanent
nursing home placement and mortality.
Krass, Wells, Guelly, and Anderson (2001)
noted the importance of case management
services for families of children with special
healthcare needs. The critical aspect of the case
manager’s role in these families was assistance in
identifying and using community-based programs
as well as the coordination of care. In particular,
the case manager assisted the family when navigating a system too
complicated to “navigate as solo pilots” (p. 183).
Gaining assistance with needed services and compliance with
medication regimens has also been documented as a positive outcome
of case management. Katz, et al. (2001) found that individuals with HIV
who had case managers were more likely to use their medications.
The common theme of these programs is to provide preventive care,
which promotes psychological and physical health and enhances
independent functioning and quality of life (Ellis, 1996). The importance
of case management as both a role for the nurse and a method of care
delivery is evident in its effectiveness pertaining to coordination, positive
outcomes, and client satisfaction.
Using the “Seven A’s” Assessment Tool for Developing Competency in Case Management
The ANA defines case
management as “...a
healthcare delivery
process whose goals are
to provide quality
healthcare, decrease
fragmentation, enhance
the client’s quality of life,
and contain costs”
28 Journal of the New York State Nurses Association, Spring/Summer 2004
How to enact case
management
Knowing how to enact the role of case
manager is important, particularly in light of
the positive outcomes of this complex process.
One method to facilitate the enactment of this
role is the asking of critical questions. The
“Seven A’s” is proposed as the framework in
the development of these questions for
community practice.
Krout (1986, 1994) and Williams, Ebrite,
and Redford (1991) identified the “Seven A’s”
as key elements in determining the success of
community agencies in providing needed
services. These “Seven A’s” include availability,
accessibility, awareness, acceptability,
affordability, appropriateness, and adequacy.
If a community agency’s primary objective is
to provide support to the individuals in the
community, how successful the agency is in
this endeavor depends on its ability to make
these “Seven A’s” a reality.
Nurses in the community fulfill their roles as
case managers when they assist individuals and
their families to identify needed services,
negotiate access into these services, and when
they determine whether there is a compatibility
between the clients’ needs and the community
agency’s ability to provide the services. It is the
nursing educator’s responsibility to develop a
nursing curriculum that includes content and
teaching strategies to guide students in
achieving case management competencies
Using the “Seven A’s” as a framework for
teaching community assessment and case
management will facilitate students’
development of competence in this role
(Table 1).
The “Seven A’s”
Awareness
Awareness involves the individual’s
knowledge and his or her ability to act on that
knowledge. In order for clients in the
community to look for a community service,
they first must be aware of their own needs.
Once this need is identified, the client may
begin the search for the community agency
that provides the service in question. Krout
(1986) noted that the primary reason for
service underutilization was lack of program
awareness. Nurses must know the questions
to ask their clients to determine whether they
are aware of services that could meet their
identified needs.
Accessibility
Accessibility is defined as the individual’s
ability to connect with an agency for a
particular service. Many clients may know of
agencies but are unable to contact them. They
may have difficulty navigating the technology
involved, obtaining transportation (Krout,
1986), or gaining entrance into buildings that
may not be handicapped accessible. Nurses
may address these issues by asking questions
that will reveal a client’s ability to access
needed services.
Availability
Availability refers to whether an advertised
service actually exists and is offered at a time,
Teaching Strategies
Awareness Educate students regarding community agencies and the services
they provide, including where and how to look for services.
Accessibility Educate students about how to access agencies and the
questions to ask once contact is made; provide advocacy and
support for students as they use technology.
Affordability Educate students about the type of payment options available
including potential financial resources.
Appropriateness Educate students about how to elicit feedback from the client
regarding service use; how to assess whether the service is
meeting the clients needs and conforming with older adults’
beliefs and values; advocacy with the agency to determine if
change is possible; identifying options regarding alternative
services.
Adequacy Assist students in determining whether clients’ needs are being
met and in advocating for older adults who may need more or
less of the service in question.
Acceptability Assist students in analyzing whether the service is sensitive to
physical, emotional, psychological, spiritual, cultural, and financial
needs of the client; provide feedback to the service agency
for their quality improvement process.
Availability Educate students about transportation options, and assist them
with participation in partnerships that strengthen lobbying efforts
for needed services.
Table 1: The “Seven A’s”
location, and place convenient for client use.
According to Krout (1986), communities that
offer a larger and broader spectrum of services
may enhance a client’s awareness and ability
to access that service. Limitations may be
attached to some services, such as income
eligibility requirements and a minimum
number of participants, which may affect
utilization (Gallagher & Truglio-Londrigan,
2004). Nurses can ask questions that will help
them gain a fuller understanding of the
availability of services. These questions must
be specific with regard to time and location of
a program, as well as the criteria for
participation and implementation.
Affordability
Affordability relates to the client’s ability
to pay for a community agency service.
Affordability depends on income, type of
Using the “Seven A’s” Assessment Tool for Developing Competency in Case Management
Journal of the New York State Nurses Association, Spring/Summer 2004 29
insurance, and whether the client’s insurance covers a particular service.
Nurses must be aware of the cost of services, agencies’ sliding scale fees,
and whether a client has economic support from family or friends.
Acceptability
Acceptability occurs when the client agrees that the community
agency service is meeting his or her needs. More often than not, clients
will acknowledge that if they are treated with care, compassion, and
expertise, they are more likely to find the service pleasing and acceptable.
Sometimes clients find that community agencies do not take into account
the diversity of individual needs. Nurses should ask their clients about
their satisfaction with the community services they are using.
Appropriateness
Appropriateness is based on the client’s determination as to whether
the service is meeting identified needs. Is there a good fit between the
client and the service agency? Some clients may find that the agency
meets their needs only in a partial way or not at all. Nurses must question
whether the provided services suit their clients and are compatible with
their specific needs.
The “Seven A’s” Assessment Tool
1. Does your client use any service agencies in the community?
Yes No If yes, which ones?
2. Does your client have a need that he/she is not able to meet on his/her
own? (i.e., food shopping) Describe.
3. Is your client aware of services that are provided in the community?
Yes No
4. Does your client know where to look for information about a needed
service?
Yes No
5. Does your client understand brochures that describe agency services?
Yes No
6. Has your client tried to contact service agencies?
Yes No
7. Was your client successful in contacting that agency?
Yes No If no, explain.
8. Does your client have transportation to agencies?
Yes No
9. Can your client afford the transportation cost?
Yes No If no, explain.
10. Is your client physically able to enter the agency?
Yes No If no, explain:
11. Does the agency provide the service at times convenient for your client?
Yes No
12. Is the agency’s location convenient for your client?
Yes No
13. Are there eligibility criteria for the service?
Yes No If yes, explain.
Adequacy
Adequacy refers to the quantity or degree of services provided by an
agency (Krout, 1986). With too little service, the need remains unmet
and may jeopardize the client’s health. If the agency provides too much
service, this may foster dependency. Nurses must ask clients questions
to determine the sufficiency of a service in meeting their needs. They
also must assess the client, the situation, and the service to determine
if there is a fit between the community service and the client’s needs.
Teaching the “Seven A’s”
There is no question that baccalaureate nursing curricula should
include content and clinical experiences related to case management.
Nursing students are expected to know the role of case manager and
should have a basic competence in this role upon graduation. Using the
“Seven A’s” as a framework for assessment in community-based clinical
practice may help to develop student competence in this role. Both
students and practitioners may use an assessment tool that provides a
series of questions to facilitate their use of the “Seven A’s.”
14. Does the client’s health insurance pay for the service?
Ye s No
15. If the client has to pay for the service, is there a sliding fee scale?
Ye s No
16. If there is no sliding fee, can the client afford the service?
Ye s No
17. Does the client receive financial support from friends or family?
Ye s No
18. If the client is receiving services, is he/she satisfied with them?
Ye s No If no, explain.
19. Does the service agency provide the client with choices?
Ye s No
20. Does the client feel that the personnel are knowledgeable?
Ye s No
21. Does the client feel that the personnel are caring?
Ye s No
22. Does the client feel that the personnel are willing to work with him/her?
Ye s No
23. Does the service meet the client needs?
Ye s No If no, explain.
24. Is the client comfortable with the service that is being provided?
Ye s No
25. Did the client feel that the amount of service provided is adequate?
Ye s No If no, explain.
Using the “Seven A’s” Assessment Tool for Developing Competency in Case Management
30 Journal of the New York State Nurses Association, Spring/Summer 2004
The “Seven A’s” Assignment
Assignments and class exercises may be developed that can challenge
nursing students, not only to assess client’s needs and identify problems,
but also to develop solutions that will help their clients negotiate the
complex web of community services. One such exercise takes place in
the classroom and begins with a case study. Practicing assessment and
problem identification in a safe, supportive environment such as the
classroom or nursing skills laboratory helps build student confidence
and leads to greater success when implementing the case manager role
in the community setting.
In this exercise, students are given detailed case studies that clearly
depict barriers to the “Seven A’s.”
Case Study with Elderly Client
As the community health nurse enters the home of Mr. Small, an 85-
year-old client, he tells her, “I don’t know what to do with my colostomy.
I have only one bag left and I forgot how to change it.” Mr. Small had
been released from the hospital two days before, after having undergone
a colon resection and colostomy for a bowel obstruction. He lives with
his wife, who is a cancer patient and unable to assist him. He was able to
function independently prior to his surgery, except for some mild short-
term memory problems. He appears to be weak, and says that he has no
idea where to get supplies for his colostomy or assistance with bathing,
shopping for food, and getting to the doctor. Mr. Small has tried
unsuccessfully to contact his primary care provider, who has not returned
his call in more than 48 hours.
Case Study with a Pediatric Client and Family
Ann and Paul arrive at a child treatment center for an interdisciplinary
conference about their 5-year-old daughter, Anita, who is developmentally
delayed. They also have an 8-year-old daughter, Marie. Shortly after Anita’s
birth, Ann noted that she did not roll over in the crib or raise her head at
the appropriate developmental milestone markers. She repeatedly raised
these concerns with primary care providers, to no avail. As the first year of
Anita’s life progressed, Ann found it increasingly difficult to feed her. Feedings
would sometimes take more than an hour.
Ann and Paul decided to take matters into their own hands. They took
their daughter to several pediatricians, who referred them to specialists,
many of whom were in other states. Although the family had primary
health care coverage, the cost of copayments, transportation, and motel
accommodations was taking an economic toll. The family was relying on
one income, as Ann had not returned to work after the birth of their first
child. Finally, one of the specialists diagnosed Anita with Down’s syndrome.
Ann says she was in a state of shock. She kept thinking that she had done
something wrong while she was pregnant, and that was the reason why
Anita was born “this way.” Paul say he remembers praying a lot.
Class Session
After reading the case studies, some students are asked to role-play
the individuals presented in the case studies. While these students
prepare, the students who will observe the role play are given the “Seven
A’s” assessment tool.
At the completion of the role play, the students who observed the
play are given time to complete the “Seven A’s” assessment tool. When
the assessment tools are completed, there is a debriefing session during
which students who participated in the play verbalize their experiences.
Self-reflective practice is important, as the students share their feelings
throughout the process and identify what it must be like for individuals
who live these experiences on a daily basis.
Students who completed the “Seven A’s” assessment tool then share
their findings with the rest of the class. Students are given time to look at
the potential barriers to community services and potential intervention
strategies the case manager may use to help individuals and families gain
access to these services. Students also discuss ways to support individuals
and families facilitate their own success in negotiating the system. For
example, nurses can teach how to locate needed services, either through
traditional sources such as the yellow pages or via the Internet.
Summary
Nursing faculty are responsible for developing curricula that include
case management content and skills. The case management skill set is
just one aspect of the multi-faceted role required for baccalaureate nursing
students to function adequately in community settings. It is essential for
faculty and nursing students to be aware of and to understand community
agencies and the services they provide. Nurses must be able to support
and assist clients and their families to be independent and active
participants in their own care.
Knowledge of community services includes service availability,
population served, cost, flexibility, location, and transportation
arrangements that can be made for clients. Nursing students, in
partnership with their clients and faculty, can use information pertaining
to community agencies and services to make informed decisions that will
allow clients to live independently in the community.
Conclusion
As the baccalaureate nursing curriculum shifts its focus to include
nontraditional community clinical learning experiences, it is clear that
applying traditional, hospital-based skills to the community is not
sufficient. The complexity of the community setting requires
baccalaureate students to be competent in roles and skills that
demonstrate breadth of knowledge and an understanding of systems and
processes. Nursing faculty must be cognizant of these roles and skills,
particularly the case management role, when developing educational
frameworks, content, and teaching strategies. The “Seven A’s” is one
such framework. Using an assessment tool based on the “Seven A’s”
may facilitate students’ development of the case management role in
the community setting.
Acknowledgement
We would like to acknowledge Dr. Rona F. Levin, project director for
the Joan M. Stout, RN, Evidence-Based Practice Initiative at the Lienhard
School of Nursing and Professor Emeritus at Felician College, Lodi, N.J.,
for her support for our endeavors. Her constant guidance is a source of
inspiration and we thank her.
Using the “Seven A’s” Assessment Tool for Developing Competency in Case Management
Journal of the New York State Nurses Association, Spring/Summer 2004 31
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