In the last ten years, disability services in Ireland have embraced the idea of person-centred planning, that is, designing a service based on the individual’s needs and goals. Under the umbrella of person-centred planning a variety of processes have been developed: Life-style Planning (O’Brien 1987); Personal Futures Planning (Mount and Zwernick 1988); The McGill Action Planning System (Vandercook, York and Forest 1989); Framework for Accomplishment /Personal Profile (O’Brien, Mount and O’Brien 1990); Essential Lifestyle Planning (Smull and Harrison 1992); and Personal Outcome Measures (The Council on Quality and Leadership in Supports for People with Disabilities 1997).
These person-centred planning activities share many similarities, including an explicit commitment to seeking five essential goals or valued accomplishments in the individual’s life (O’Brien 1987):
- Being present and participating in community life.
- Gaining and maintaining satisfying relationships.
- Expressing preferences and making choices in everyday life.
- Having opportunities to fulfil respected roles and to live with dignity.
- Continuing to develop personal competencies.
What is still needed is a method of coodinating these plans to oversee the effectiveness of the overall service delivery to individuals. To meet this need, a new service function has been developed, that of service coordination, and subsequently a new health professional, the service coordinator.
Planning is a very important component of service delivery for people with disabilities. Individual programme plans constitute a real life planning process and without the effective coordination of such plans, individual goals will not be met.
This process deals with important questions for both the service and the individual:
- Can the service meet the needs defined by the individual?
- How will the information be presented collectively to advocate for further resources?
- Is the overall plan of service person-centred, embedded in a system that supports monitoring, implementation and achieving outcomes?
- Does the service have a response rate and achievement measure for individual needs?
In present service delivery systems, ‘key workers’ are empowered to participate in the assessment, identification of needs and goals of service users and are responsible for the day-to-day implementation of the service plan. They also document progress, goals achieved and goals still to be achieved. If the key-worker leaves, there is no system that carries the plans forward. In the absence of service coordination, there is no monitoring, limited implementation of the plan and limited outcomes for the individual.
It is not sufficient to improve the coordination of existing services or the introduction of multidisciplinary assessment; what is needed is a coordination structure/system that is embedded in service delivery and relates to individual needs and improved quality of life over the long-term. The introduction of service coordination represents long-term support to produce relevant services for people with disabilities.
The service coordination process
Service coordination should include the following six basic elements:
- Identification of high risk/high cost cases.
- Assessment of the individual’s needs, supports and goals.
- Development of an overall plan of service, in conjunction with the individual, the family and the team of staff currently supporting the individual.
- Implementation, either directly or by coordination, of needed services in a cost-effective and organised manner.
- Ongoing evaluation of the plan in relationship to the desired identified outcome.
- Service review of the role and effectiveness of individualised service coordination.
The ideal system flows from identification of need (disability) and is designed to achieve quality of life for the individual and their family on a continuing basis. There is a need for systematic review and a template for an overall plan of service. This template should incorporate the five essential goals (O’Brien 1987) and include an assessment of the individual’s needs, supports and goals. Objectives and targets should be documented and reviewed every three months by the team (including the individual and his/her family) and reported to the service coordinator. The organisation must also review the process from all these perspectives.
Functions of a service coordinator
The service coordinator will have multiple functions—monitoring and feedback, brokering for additional services/resources, advocacy and supportive intervention, and reviewing the effectiveness of the plan in achieving the desired outcomes for the individual. It is not imperative that a service coordinator attend all planning meetings; what is imperative is that they receive a copy of the plan with goal statements, how these goals will be addressed and the person responsible for implementing each goal.
There are two general types of service coordinators. An internal service coordinator follows procedures that are governed by their employer and coordinates all the services available within the service agency, based on the individual client’s needs. External coordinators are contracted for a specific need (education/finance/legal) or to do an evaluation of service for an individual client and make recommendations for treatment and services.
For the maximum outcome within the continuum of care, internal and external service coordinators may work together directly. The service coordinator should facilitate communication and coordination between all members of the team, involving the individual and family in the decision-making process in order to minimise fragmentation of the health-care delivery system.
Because the coordination of care in the community involves so many different agencies/disciplines, there may be questions about the service coordinator’s authority to influence and control the resources of an agency. It has been said that there are four sources of authority: clinical, legal, fiscal and administrative, and some writers have stressed that the service coordinator requires organisational legitimacy that authorises and supports the activity (with legal and fiscal) leverage and that without authority it becomes freelance advocacy. Schwartz et al. (1982) are clear that service coordination ‘can be most successful only if agency administration have established inter-organisational supervisory structures to support it’.
Research on service coordination
There have been several studies on the effectiveness of different models of service coordination. ‘Treatment matching’ for clients, the development of an overall plan of service based on person-centred support, is reported in the psychotherapy literature and can also be applied to service coordination models. A number of effectiveness studies have been conducted and three key features distinguish successful programmes from less successful ones:
- Successful programmes were specific about their objectives.
- They were specific about the coordination model which they used.
- They were specific about the target group/individuals they supported.
There has been a lack of consensus and clarity regarding the role of service coordinators in the field of mental health (Bachrach 1989, 1993). A study by Hromco et al. (1997) explored five functions of case management by surveying 230 case managers in three US states. The authors identified that 70% of case managers rated ‘formal therapeutic intervention’ last or next to last in order of importance. In contrast, 68% rated ‘supportive interventions’ first or second. Linking and brokering functions and the monitoring/crisis intervention function were ranked second and third, while advocacy was most frequently ranked fourth. Supportive interventions resulted from the coordinator’s understanding of the needs of an individual and their family. It is evident from this study that a majority of coordinators place a high value on the professional relationship with the individual, the family and the service.
Hromco et al. (1997) highlight that over one-third of service coordinators’ time is spent in administrative tasks—this must be considered in planning for the implementation of service coordination.
Another significant variable is that if the organisational structure does not support individualised service coordination, the field will have created yet another specialist service which may ‘silt up’. What is needed is a mechanism that is user-friendly, easily implemented and easily reviewed by every member of the service team.
The coordination of service delivery is not new to the field of learning disability. What is new, in Ireland, is the idea that the coordination of services for an individual is a long-term process. Individuals with disabilities and their families often find that service delivery is fragmented, without an overall plan. Service coordination is essential to facilitate individuals to shape their service and improve their lifestyle.