Vagueness and Ambiguity in Communication of Case Management: A Content Analysis in the Australian National Disability Insurance Scheme

Introduction

Case management (CM) makes a unique contribution to the integration of community-based care and multiple sectors supports, to support the person and achieve their goals [123]. CM differs from system-based integration (or coordination by professionals across their services), because of the relationship the case manager has with the user. In both literature and practice the term CM and care coordination are used synonymously for both relational CM and system-based care coordination. In this paper we refer only to CM where there is a ‘relational continuity’ and a continuous (professional) relationship between the case manager and user (p.6 [4]).

CM effectiveness is demonstrated for planning and coordination of health and social support services, and positively impacts on individual outcomes, social and economic participation [5678]. Despite this, over many years of CM quality, evaluation studies and systematic reviews in different countries, contexts, and health conditions, were beset with difficulties. The variability and complexity of CM is often underscored as a key issue, yet the value and adaptability of CM interventions is highlighted [910]. Overwhelmingly, authors conclude the key difficulties are due to inconsistencies and ambiguity in definitions, vague descriptions in communication and lack of a common language for CM [11121314]. The high variability occurs with the factors of context, service setting, health condition, model, position title, discipline and skills of the case manager and actions performed [15]. Vague and ambiguous communication on CM is highly problematic for policy, service planning, implementation, outcome measurement and quality analysis [91516]. Decades of employment research on the communication of roles and responsibilities, has also shown that ambiguity and vagueness in role descriptions negatively impacts on service user expectations and outcomes, job satisfaction and staff turnover, intra-organisational collaboration, and personnel job performance [171819].

In 2013 the Australian Government launched the National Disability Insurance Scheme (NDIS). The NDIS provides individualised funding for health and social supports to eligible people with a disability. To be eligible the person must have a permanent disability, that significantly affects their ability to take part in everyday activities and under 65 years old. The direct funding to the Scheme participant enables them to choose, coordinate and purchase the available services that meet their needs [2021]. Each participant undergoes a planning process including setting their own goals, from which reasonable and necessary services are costed and submitted for approval. The NDIS recognised the need for CM in its policy and operationalisation, and embedded CM in its structures, although the role is called by other names [2223]. Every participant in the NDIS has a case manager involved in the goal setting and planning process for funding. Once funding is allocated, further CM services may be provided to the participant although the specific CM actions vary depending on the needs (e.g. service availability, participant supports), and funding allocated for CM [24]. The various case manager roles in the NDIS provide a critical participant support to navigate the system, have choice and make decisions on, and coordinate support services, and service providers [25].

Our study used a top-down nested hierarchical content-analysis of components in CM role descriptions. We examined official documents and job positions of the case managers in the NDIS in New South Wales (NSW). The aim was to answer the following questions:

• – Is the NDIS case manager job, role/s, and actions (interventions) clearly and consistently communicated in key documents (governance documents; operational guidelines; general (service) information; job descriptions; job advertisements)?

• – Has the role/s and action description changed over time (from the pilot, roll- out and finalisation of implementation)?

• – Is there vagueness, ambiguity, or gaps in the descriptions of the role/s and interventions of case managers?

In Table 1 there is an outline of the implementation stages of the NDIS and CM job titles, employer organisations and geographic areas.

Methods

We analysed documents from the Australian Government and one state, New South Wales (NSW). The reasons are NSW was one of the four (of seven) states/territories in Australia in the pilot; national implementation occurred over years; NSW implemented the NDIS state-wide early: NSW has the highest population thus more people employed in NDIS related CM jobs.

In this paper we refer to the: job as the paid case management position; role as the function and purpose of the person employed in the job; and actions, which are the interventions/activities performed by the person in the job.

We conducted a content analysis of the publicly available official and primary source documents detailing CM jobs, role, and actions in the NDIS national context and specifically in NSW from the period 2013–2019. We used a top-down nested hierarchy and selected informative documents including NDIS reference documents and real-world information documents of case manager’s job requirements, the role, and actions.

Findings

We found ambiguity and vagueness in the CM definitions of the LAC from the employer partner organisations. There was a total of 28 unique definitions of CM roles in the NDIS documents and advertisements alone. We also found communication gaps on expected case manager actions across the various job descriptions for the same job but with different employers. There was poor role communication on the three support coordinator jobs with high variability in job title, job descriptions of roles and no adequate descriptions of actions required in these roles.

Stage 1

Document search

Figure 1 provides the results from the internet search completed 6 – 20 March 2017.

Figure 1

Appendix 2 provides the references of documents analysed after exclusions from Stage 1 (n = 43) and Stage 2 (n = 10). The 2017 NDIS internal employee position of employed planner position description was not publicly available. There were no job descriptions for support connection, nor specialist support coordinator. Table 4 provides the number of documents analysed per document category.

Table 4

Categories of analysed documents.

DOCUMENT CATEGORY	DOCUMENTS ANALYSED 2017	DOCUMENTS ANALYSED 2019
Governance documents	3	0
general (service) information	21	0
Operational/practice guides	14	2
job descriptions	2	7
job advertisements	3	3

Content Analysis

In Step 3 and the first level of analysis (refer to Table 2 phases of content analysis) there were 24 sub-categories of semantically distinct phases in the text across documents. Table 5 lists the 24 sub-categories.

Table 5

Content extraction and analysis sub-categories.

SUB-COMPONENT CATEGORIES (N = 24)
Provides support to implement plan	Develops goals for the next plan/reviews current plan	Assesses the participant or refers for assessment
Navigates, finds, connects, links with community supports	Investigates additional training/education options	Collates information to share with the team/completes compliance reporting
Provides technical support	Communicates any issues/barriers to stakeholders and implements solutions/strategies and problem solves	Educates external providers to enhance their ability to include individuals with disability
Explains how to identify options for further supports and priorities	Make decision/provides decision making support about needs and goals for completing plan	Coordinates the external services providers
Teaches how to enter service agreements	First point of person contact	Engages in activities to support ongoing development of the role
Maintains supports and has ongoing communication with participant	Discusses future long-term goals	Promotes inclusion and participation in the community
Monitors achievement of goals	Identifies risks and safeguards	Encourages changes in societal beliefs and disability
Explains the plan and provides information/answers questions	Assists with scheduling appointments and services	Advocates for human rights

The first two authors mapped the 24 sub-categories to the 9 main action categories in the CMTaxonomy until consensus reached. Table 6 details the 24 sub-categories mapped to the CMTaxonomy main actions.

Table 6

Content analysis to CMTaxonomy categories – main actions.

	CMTAXONOMY MAIN ACTIONS
SUB-CATEGORIES OF SEMANTICALLY DIFFERENT PHRASES (N = 24)	ENGAGEMENT	HOLISTIC ASSESSMENT	PLANNING	EDUCATION	TRAINING AND SKILLS DEVELOPMENT	EMOTIONAL AND MOTIVATIONAL SUPPORT	ADVISING	COORDINATION	MONITORING
Provides support to implement plan			✓	✓		✓	✓	✓
Navigates, finds, connects, links with community, supports								✓
Provides technical support					✓
Explains how to identify options for further supports and priorities			✓	✓		✓	✓	✓
Teaches how to enter service agreements					✓
Maintains supports and has ongoing communication with participant			✓					✓	✓
Monitors achievement of goals									✓
Explains the plan and provides information/answers questions			✓	✓			✓	✓
Develops goals for the next plan/reviews current plan			✓
Investigates additional training/education options			✓				✓
Communicates any issues/barriers to stakeholders and implements solutions, strategises and problem solves				✓		✓	✓	✓
Make decisions/provides decision making support about needs and goals for completing plan			✓	✓		✓
First point of client contact	✓
Discusses future long-term goals			✓			✓
Identifies risks and safeguards			✓				✓
Assists with scheduling appointments and services								✓
Assesses the participant or refers for assessment		✓
Collates information to share with the team/completes compliance reporting								✓
Educates external providers to enhance their ability to include individuals with disability				✓	✓
Coordinates the external service providers								✓
Engages in activities to support ongoing development of the role
Promotes inclusion and participation in the community
Encourages changes in societal beliefs of disability
Advocates for human rights

Below is a summary which outlines the inconsistency, vagueness, and gaps across documents. The summary starts with higher level of the hierarchy, the basic information (e.g., job title) and moves down the hierarchy to more detailed information on the job description of the role and then the case manager’s actions (interventions).

The job title used by the NDIS varied between documents with ‘local area coordinator’, (n = 15), ‘planner’ (n = 9) and ‘support coordinator’ (n = 2) creating ambiguity and confusion. We found 50 definitions (17 unique) in general NDIS documents and 16 definitions (11 unique) in NDIS job advertisements alone.

There were: four definitions (three unique) in two NDIS operational guidelines; 52 definitions (including 16 unique) in general information NDIS documents; 27 definitions (including 17 unique) in NDIS job descriptions; 16 definitions (including 11 unique) in job advertisements.

The most described sub-category in NDIS was ‘navigates, finds, connects, links with community and supports’ (n = 22 documents) located in operational guidelines; two operational documents; eight general information documents: one general document reporting on the ‘planner’ position; two general documents for ‘support coordinator’ role; job description and advertisements.

The CM sub-categories mostly commonly used (eight or more times) in NDIS documents: ‘navigates, finds, connects, links with community and supports’, ‘explains how to identify options for further supports and prioritise goals’, ‘maintains supports and has ongoing communication with participant’, ‘monitors achievement of goals’, ‘explains the plan and provides information/answers questions’, ‘develops goals for the next plan and reviews current plan’ ‘monitors achievement of goals’, ‘communicates any issues/barriers to stakeholders and implements solutions, strategies and problem solves’, ‘explains the plan and provides information/answers questions’ and ‘develops goals for the next plan/reviews the current plan’.

The most infrequent CM sub-categories or unique to a specific role included ‘educate external providers’ for the LAC role (NDIS guideline and St Vincent de Paul). In ‘LAC’ job position advertisements, the role of ‘promotes inclusion and participation in the community’ and ‘encourages changes in societal beliefs of disability’ was included.

Descriptions unique to NDIS support-coordinator in general information included ‘assists with scheduling appointments and services. Categories of activities used only in NDIS documents include: ‘provides technical support’, ‘teaches how to enter service agreements’, ‘educates external providers to enhance their ability to include individuals with disability’, ‘engages in activities to support ongoing development of the role’, ‘encourages changes in societal beliefs of disability’, ‘advocates for human rights’. These actions could not be mapped to the CMTaxonomy actions being actions in the domain of community development and business development, not individual case management.

In the pilot phase of NDIS, the terms ‘Case Manager’ and ‘Local Area Coordinator’ were used interchangeably [3233]. The most used term was LAC, followed by planner and case manager, then support coordinator.

The LAC key responsibilities, and actions are the case manager’s role to support the participant. However, we found since 2013 LAC job descriptions also tasked them with community development of service providers with actions and responsibilities. Job descriptions included: “Contribute to building inclusive communities through partnership and collaboration with individuals and families/carers, local organisations and the broader community” (p.4 Candidate information pack 25 October 2013); ‘advocates for human rights’; ‘promote inclusion and participation in the community’; ‘encourage change in societal beliefs’; ‘educating external providers (to enhance their ability to include individuals with disability)’.

Discussion

Quality analysis and appraisal is critical to the future development of integrated care approaches and in particular a frequently used component, that of CM. To our knowledge, our study is the first analysis of the quality of the communication of the CM jobs, roles, and actions in a national disability system. We found there was ambiguity, vagueness and gaps resulted in poor communication of the role. We examined key documents on the roles of CM with the Australian NDIS from 2013–2019 with a focus on New South Wales. There are five CM roles funded in the NDIS Scheme.

The implementation of the NDIS has shown significant systemic problems impacting participant experiences in the planning, implementation and integration of their care [36]. Operational and quality challenges have arisen with case manager jobs and actions around person-centred planning and CM in the NDIS [12]. Various reports and enquiries on the NDIS report on participant’s confusion of CM role/s, expectations, responsibilities, concerns on the skill levels of case managers employed in the role, and outcomes of case manager actions [37]. The issues are reflected in the mounting quantitative evidence of 34% increase in NDIS planning and coordination support related legal reviews; participant appeals of decision made on plans appearing before the Administrative Appeals Tribunal; and the 400 complaints to the Commonwealth Ombudsman between 2016–2018 [20223839] and in NSW [21]. Ambiguity and gaps in communication on this critical NDIS case manager role and actions have contributed to participants confusion, expectations and poor experience of planning and outcomes. In part these failures and continuation of the issues led the Joint Standing Committee on the NDIS to establish an inquiry in July 2019 into NDIS implementation and performance issues [40] and another specific inquiry on case manager’s planning announced as recently as August 2019 [4142]. The NDIS commenced a consultation process on support coordination with external stakeholders in August 2020 [43].

In the organisational psychology and occupational research literature role conflict and role ambiguity have been linked to employee burnout [44]. The more unclear the job description, the higher the role ambiguity, which leads to role conflict, occupational stress, and intention to quit [454647]. Ambiguous and vague communication of work roles and actions also negatively affects job satisfaction, job performance and success, recruitment, role expectations and confusion around work tasks [484950]. In contrast, consistent communication supports good governance, establishment of work standards for specific roles, quality appraisal and analysis, and workforce capacity building [5152]. These are clear lessons for the CM roles for best practice integrated care including the NDIS sector and the impacts on the related workforce, of the current ambiguity and gaps in the poor role communication of CM.

The vagueness, ambiguity and gaps began in the pilot phase in 2013 and continue with further fragmentation with the recent creation of additional support coordination roles. Not all participants require or seek the same level of case manager support. CM jobs need opportunities to adapt their actions to meet local and participant needs appropriately for the context. However, it is clear from the mounting evidence, the ongoing ambiguity and gaps in the communication and lack of a shared vision on all CM NDIS roles, the expectations for actions to be performed by job incumbents has contributed to the variability in the operationalisation, quality, and outcomes for both the organisation and participant. Despite this, there has been little attention to the vagueness and ambiguity, and gaps in the communication of case manager jobs, roles, and actions, even though this is clearly a contributing factor to the current situation. The importance and need for an ontological approach with health and social care roles such as CM, which provides a common language, clear unambiguous communication on actions is well established [1653]. This study highlights the need for an ontological approach to CM in the NDIS sector with greater attention towards quality and unambiguous communication on CM jobs and actions.

Limitations

The study excluded one CM job in the NDIS, the ECEI. Parents typically perform some case manager actions in their role as parent of their children e.g., choice, assessment of need, support of the child and coordination of services. As the ECEI job role is different when compared to CM with adults, it was excluded.

We provide the reasons for including documents for only one state. There may be less ambiguity and vagueness in communication on the CM role and actions in different states, for example, if there is one partner organisation.

Conclusion

Our study analysed the communication of CM in the context of the NDIS with a focus on NSW. The CM role is fragmented across various positions and there are gaps in the roles. The evolution into five different CM roles resulted in ambiguity and poor role communication. There is evidence through the numerous complaints and enquiries, of the impact of this on the quality and integration of care for participants of the Scheme. Future work may involve standardising the communication of the CM roles in the NDIS sector. An ontological approach to describing case management roles is needed. Such an approach uses a common language (such as a taxonomy), unambiguous and comprehensive communication at all levels and across industry related organisations to support best practice in policy, governance, workforce recruitment and capacity-building. The ontological approach would enhance the successful operationalisation of the NDIS and participant outcomes from planning and coordination. There are lessons on the importance of communication of a complex integrated care strategy such as CM communication for similar schemes in other countries and contexts.

Additional Files

The additional files for this article can be found as follows:

Reviewers

Dr Daniel Rock, WA Primary Health Alliance, Perth, Western Australia. One anonymous reviewer.

Competing Interests

The authors have no competing interests to declare.