Establishing a transdisciplinary competency framework for interdisciplinary case management practice in long-term care: a participatory Delphi study

Abstract

Background

The World Health Organization has identified the long-term care system as a critical area for enhancing the health and quality of life of older adults. Within this system, case management is a prevalent service delivery model implemented by interdisciplinary teams comprising professionals from various sectors. However, the absence of a comprehensive transdisciplinary competency framework applicable across different disciplines obstructs the development of relevant training programs and hinders workforce capacity building and professionalization. This study was conducted in the context of Hong Kong’s long-term care system and aimed to establish a transdisciplinary competency framework through expert consensus to advance case management practices.

Methods

This study employed an online five-stage participatory Delphi approach, with two rounds of questionnaire surveys and three roundtable discussions. The expert panel featured 40 health and social care professionals in the long-term care field. Their task was to develop a list of essential competencies for the long-term care workforce in case management. To determine the list of competencies, metrics such as the percentage of agreement, mean rating scores for each statement, and interquartile range were assessed using a 5-point Likert scale that measured clarity, relevance, and importance.

Results

The panel reached consensus on a comprehensive transdisciplinary framework that includes 49 competencies organized into six key domains: overarching values; knowledge of long-term care and case management practices; assessment skills; analytical and intervention skills; communication skills and teamwork; and advocacy. Experts highlighted that this framework can significantly improve the capacity-building efforts of interdisciplinary teams involved in long-term care case management. The competencies are further organized into three progressive levels—basic, intermediate, and advanced—to support the growth of practitioners’ professional skills.

Conclusion

The proposed transdisciplinary competency framework provides a foundation for developing and implementing training curricula for frontline professionals in the long-term care sector. Governments can utilize this framework to create career progression pathways that attract more talent to the field and enhance the supervision and evaluation of practitioners’ competencies. This approach will help ensure the quality of long-term care services.

Introduction

Long-term care (LTC) services are receiving growing attention worldwide. The World Health Organization (WHO) has identified LTC as a crucial action area in its Decade of Healthy Ageing plan to enhance older individuals’ health and quality of life [1]. LTC refers to an integrated system of medical, personal, and social services designed to meet the ongoing needs of individuals experiencing functional decline. It aims to maintain quality of life, maximize functional independence, and enable aging in place through a continuum of care that addresses both clinical needs and non-clinical support, tailored to individuals’ changing levels of frailty [2]. According to the WHO’s framework for achieving an integrated continuum of long-term care, robust LTC systems should be anchored by three principles: person-centeredness; equity, affordability, accessibility; and respect for human rights and dignity. These principles guide the development and implementation of key system elements, such as workforce, service delivery, and innovation and research [3].

Case management is a fundamental approach to delivering LTC services. It is a collaborative process in which professionals assess client needs, coordinate services, advocate for appropriate resources, and develop individualized care plans to achieve optimal health outcomes in a cost-effective manner [4]. Case management enhances adherence to treatment or rehabilitation plans, alleviates the burden on clients’ families [5], and can decrease the need for hospitalization, enabling clients to remain in familiar environments for longer [6].

Interdisciplinary teams in long-term care case management practice

Globally, LTC case management is typically executed by teams featuring health and social care professionals from various sectors and disciplines. The WHO defines an interdisciplinary team as a group of individuals who work interdependently toward common goals while maintaining their distinct professional responsibilities [2]. The term “interdisciplinary” highlights collaboration and interaction among various disciplines [7]. An interdisciplinary team represents a cooperative effort across different professional fields, placing a stronger emphasis on a person-centered approach [8]. This focus on collaboration and person-centered care is paramount, as the most critical aspect of an LTC team is not the specific professions represented but the core competencies required to deliver services effectively and meet client needs [2].

Using interdisciplinary teamwork to enhance LTC services has become a notable trend, with many Western countries accumulating valuable experience in this domain. In the United States, there is a strong emphasis on interdisciplinary education within healthcare training, supported by federal guidelines that regulate interdisciplinary care across diverse settings [9]. England has implemented community-based interdisciplinary care programs involving at least four types of professionals to reduce hospital admissions among older adults [10]. Similarly, in Australia, urban healthcare services prioritize the formation of interdisciplinary teams by recruiting professionals from various disciplines to meet the increasing care demand due to the aging population [8]. The specific composition and structure of interdisciplinary teams depend on regional needs and workforce availability, typically including certified nursing aides, registered nurses, social workers, physical therapists, occupational therapists, physicians, and other care workers [2, 10].

Transdisciplinary competency framework for interdisciplinary collaboration

Previous research has indicated that a well-defined competency framework plays a crucial role in enhancing workforce capacity and fostering professional development in service delivery [3, 7]. However, existing competency frameworks are either limited to a specific profession, such as registered nurses [11], or provide only general guidance for elderly services [12]. This often leads to a mismatch with the unique needs and the interdisciplinary nature of LTC case management. There is a notable lack of comprehensive competency frameworks that provide detailed guidance across the entire interdisciplinary team.

To address this gap, we adopted a transdisciplinary theoretical perspective to construct the competency framework. The transdisciplinary approach emphasizes “transcending” traditional professional boundaries, drawing on knowledge from different disciplines to create a cohesive whole [13]. This perspective guides us in synthesizing diverse disciplinary insights into a holistic framework that addresses real-world problems in a practical care setting [14].

It is important to clarify the terminology used in this study: “interdisciplinary” is applied to describe teams or case management practices that involve interaction among experts from different disciplines, whereas “transdisciplinary” is used to characterize the competency framework itself. The transdisciplinary nature of the framework indicates that it extends beyond discipline-specific knowledge and is applicable to professionals from various backgrounds.

Accordingly, this study aims to establish a transdisciplinary competency framework that seamlessly blends interdisciplinary experiences and incorporates knowledge from both science and practice, thereby guiding interdisciplinary LTC case management practice. A clearly defined competency framework within LTC systems can facilitate the identification and training of qualified health and social care professionals, as well as monitor ethical practices that safeguard clients’ well-being [7].

Long-term care case management practices in Hong Kong

The study was situated within the context of Hong Kong, where the government formally established the LTC system in 2000 and has since progressively strengthened case management services [15]. In Hong Kong, the primary users of LTC are older adults. These services are divided into two streams under different governance structures. The first and predominant stream is administered by the Social Welfare Department (SWD), encompassing both community-based and residential care services [16]. In the 2024–2025 financial year, SWD-subsidized LTC services covered nearly 120,000 older adults [17]. Community care services offered 33,110 service places, while residential care services provided 33,566 subsidized places. In addition, interdisciplinary outreach support teams support 52,482 beneficiaries [17]. The second category, overseen by the Hospital Authority (HA), provides general infirmary services for people with complex health needs that exceed the welfare sector’s capacity and require hospital-based long-term care [18]. However, this stream is comparatively limited in scale, with fewer than 2000 infirmary beds across Hong Kong [19]. Consequently, in both policy discourse and service delivery, the term “long-term care” in Hong Kong mainly refers to the SWD-managed system.

Within the SWD-administered LTC framework, case management is delivered by interdisciplinary teams comprising registered social workers, enrolled or registered nurses, occupational therapists, physiotherapists, speech therapists, care workers, and rehabilitation assistants [20]. Distinct from HA-managed hospital infirmary models, physicians are not typically part of community or residential LTC case management teams. Instead, medical services are integrated through a separate “Visiting Medical Practitioner Service”. Under this arrangement, LTC facilities engage physicians on a contractual basis as visiting medical officers to provide regular medical support to care recipients [21].

This study utilized a participatory Delphi approach that engaged experts from various disciplines in the field of LTC. Before this study, the research team conducted a literature review of existing case management competency frameworks. This review included profession-specific frameworks (e.g., for registered nurses) [22], discussions of principles of interdisciplinary collaboration [10], and core competency models for case managers developed in culturally similar contexts [23]. Based on this review, an initial competency framework was drafted to serve as a foundation for further development. This preliminary framework was then refined and expanded through the participatory Delphi approach. Through multiple rounds of roundtable discussions and surveys, a consensus was reached among the experts. The resulting transdisciplinary competency framework can be applied to the development of training curricula and capacity-building programs for health and social professionals working in LTC settings. Such an application would help meet the needs of older adults who expect to age in place [24, 25], improve the quality and efficiency of LTC case management services, and enhance the professionalism of service providers.

Method

Participatory Delphi approach

We employed the participatory Delphi method in this study. The Delphi technique is a scientific and robust approach to examining new changes and opportunities or gaining insight into complex phenomena [26], and it has been frequently used in healthcare research [27, 28]. Through a multistep iterative process, this method allows stakeholders to express their perspectives freely, modify their opinions, and ultimately reach a consensus [29].

Participatory Delphi is a modified version of the traditional Delphi method. Compared with the traditional approach, it incorporates more interactive steps to encourage participants’ input when constructing a framework or scale [30]. This includes conducting focus group interviews and roundtable discussions before, between, or after several rounds of anonymous voting [31]. Although this type of adaptation has generated concerns about the risk to the anonymity of participants during the discussion because they need to work together to deal with conflicting views, some evidence shows that this modification process does not fundamentally diminish the validity of the Delphi approach [32].

The participatory Delphi method has characteristics that align with our study [30]. The first is the purpose of change. We aimed to establish a competency framework for LTC case management practitioners, and based on this, we intend to change and develop the training and learning system to improve practitioners’ capacity. The second quality involves having a diverse group of stakeholders and incorporating community knowledge and values. LTC management requires interdisciplinary teams, so we recruited representatives from collaborating units, academics, professional associations, and community services to facilitate a comprehensive understanding of LTC case management. By actively involving these stakeholders in the item development process and incorporating their input, we ensured that diverse perspectives were summarized in the final framework. Third, we also provided participants with the necessary resources and relevant information during the study to facilitate their participation.

Delphi process

This study lasted six months in 2022, including three rounds of discussion and two rounds of consensus questionnaires (see Fig. 1). This process ensured that participants could not only vote independently but also understand and exchange views with one another. Because of the COVID-19 pandemic, all five steps were conducted online (discussion meetings via the Zoom platform and consensus questionnaires via Qualtrics). This online method helped us bring together experts across geographic boundaries, greatly saving time and improving the efficiency of data collection.

Fig. 1.

Flowchart representing the Delphi process

The expert panel was formed through a joint effort between the research team and a statutory organization comprising over 520 member agencies providing services throughout Hong Kong. To ensure the competency framework was both scientifically rigorous and practically applicable, the panel included senior academics and frontline practitioners specializing in LTC. Academics with strong expertise in LTC research in Hong Kong were purposively selected and invited via email. Meanwhile, practitioners were identified by contacting LTC facilities across districts and requesting nominations from their case management teams. Invitations were then emailed to the selected nominees. Ultimately, 40 experts agreed to participate and signed informed consent forms. The panel comprised registered nurses, social workers, physiotherapists, occupational therapists, speech therapists, university professors, district health center representatives, and representatives from direct services units. This composition reflected the core disciplines of Hong Kong’s mainstream LTC system, and the inclusion of academic experts further strengthened the scientific foundation of the framework development.

During the preparation phase before the Delphi process, the research team reviewed existing studies on core competencies in LTC case management and developed an initial list of 18 competencies [22, 23]. These competencies covered key areas such as value acknowledgment, comprehensive assessment, individualized care planning, care coordination, interdisciplinary collaboration, and service monitoring. This preliminary list served as a reference to guide panelists in the subsequent roundtable discussion.

The first roundtable discussion aimed to generate a comprehensive list of competencies for the workforce involved in the LTC case management practice, which would later be used for consensus questionnaire surveys. Participants were divided into eight groups to discuss the question, “What competencies are expected for the workforce to contribute to the case management practice (CMP)?” Participants were asked to provide suggestions and generate additional items based on the initial 18-item list. After the group discussion, a project facilitator collected and consolidated the recommendations regarding relevant categories of professionals and competencies from each group.

A consensus questionnaire, featuring the compiled competency list, was distributed to panelists via email to ensure independent responses and anonymity. Participants had 2 weeks to complete the online questionnaire during each round, with reminder emails sent at 7 and 10 days for those who had not finished the survey. Each item in the competency list was presented with a 5-point Likert scale (1 = strongly disagree to 5 = strongly agree), enabling panelists to rate the statement’s clarity, relevance, and importance. Following each rating, an open textbox allowed them to justify their score and provide comments.

Following the completion of the first round of questionnaires, researchers analyzed and summarized the ratings. Based on the panelists’ feedback, appropriate adjustments were made to the wording of certain items. Two weeks after the first survey, panelists received a revised questionnaire that included a summary of the panel scores. They were asked to reevaluate each item and provide further recommendations. To enable direct comparison of ratings and track the evolution of consensus, the item set was kept identical across both rounds, with no items introduced or removed in the second round.

In this study, consensus was measured using three indicators: (a) percentage agreement, which refers to the proportion of ratings of 4 (agree) and 5 (strongly agree); (b) mean rating scores for each statement; and (c) interquartile range to indicate variance [33]. The threshold for consensus regarding each statement was a percentage agreement of 85% or higher, a mean score of 4.0 or higher, and an interquartile range of 1.0 or less [26, 31].

After completing two questionnaire rounds, all 40 panelists were invited to the second roundtable discussion. During this session, we presented the combined results of the two rounds of questionnaire scoring and clearly highlighted the level of consensus achieved on each item. Items that failed to meet the predefined criteria for clarity, relevance, and importance were excluded. Items with a relevance agreement exceeding 95% were automatically included. The remaining items, which met the basic consensus thresholds but fell below the 95% automatic inclusion criterion for relevance, were subject to further discussion and a dichotomous voting process by the panelists to determine their inclusion or exclusion. After finalizing the competency framework, a follow-up meeting was held to discuss potential tiers for these items, with the aim of establishing guidelines for future training courses.

Ethical approval of this study was granted by the Hong Kong University Human Research Ethics Committee (Ref: EA220362).

Results

Survey responses

Forty experts took part in the Delphi consultation, and their backgrounds are presented in Table 1. The expert panel consisted of individuals from six professions, with most of them engaged in LTC services at the time of the survey. More than 60% of the panelists had more than 10 years of work experience, and eight panelists had worked in the eldercare field for more than 20 years. Additionally, 28% had undergone formal case management training or teaching.

Table 1.

Demographic characteristics of the Delphi participants (N = 40)

		N	Percentage
Gender	Female	32	80
	Male	8	20
Current work	Community Long-term care and support services	28	70
	Residential care homes	7	18
	Academics	2	5
	Hospital or Care Facilities	2	5
	District Health Centre	1	3
Profession	Social Worker	32	80
	Nurse	3	8
	Physiotherapist	2	5
	Occupational Therapist	1	3
	Speech Therapist	1	3
	Academic	1	3
Working years	Less than 5 years	5	13
	5–10 years	10	25
	11–15 years	8	20
	16–20 years	9	23
	Longer than 20 years	8	20
Experience in case management training/teaching	Yes	11	28

First roundtable discussion

All 40 panelists attended the kickoff meeting and the first roundtable discussion. During the session, experts exchanged perspectives from various disciplines and integrated them into a set of shared competencies and knowledge. Following group discussions, a list of 59 competency items was developed across six domains: (1) Overarching Values; (2) Knowledge of Long-Term Care and Case Management Practices; (3) Assessment Skills; (4) Analytical and Intervention Skills; (5) Communication Skills and Teamwork; and (6) Advocacy. These items were evaluated in the following two rounds based on their clarity, relevance, and importance.

First consensus questionnaire survey

Results of the consensus questionnaire collected from the 40 panelists revealed that they had reached consensus regarding relevance and importance for all six items in Domain I, 11 of 14 items in Domain II, all nine items in Domain III, 14 of 15 items in Domain IV, all 10 items in Domain V, and three of five items in Domain VI (see Table 2). Items with lower relevance scores tended to receive lower scores on importance.

Table 2.

Results from two rounds of the consensus questionnaire (*rephrased items)

Domain	Item no	Mean						Percentage of agreement
		Clarity		Relevance		Importance		Clarity		Relevance		Importance
		1st	2nd	1st	2nd	1st	2nd	1st	2nd (%)	1st (%)	2nd (%)	1st (%)	2nd (%)
Straightly included items: 2nd agreement of relevance ≥ 95%
Domain I: overarching values	1.1*	4.03	4.23	4.48	4.50	4.60	4.63	87.5	95.0	100.0	100.0	100.0	100.0
	1.2*	4.03	4.08	4.25	4.25	4.38	4.40	82.5	87.5	97.5	97.5	100.0	100.0
	1.4	4.20	4.25	4.43	4.43	4.53	4.53	97.5	100.0	97.5	97.5	100.0	100.0
	1.6	4.53	4.55	4.30	4.33	4.50	4.53	100.0	100.0	95.0	95.0	100.0	100.0
Domain II: knowledge of long-term care and case management practice	2.1*	4.18	4.28	4.50	4.55	4.63	4.65	90.0	95.0	100.0	100.0	100.0	100.0
	2.2*	4.28	4.33	4.50	4.50	4.55	4.55	97.5	100.0	100.0	100.0	100.0	97.5
	2.4	4.18	4.18	4.25	4.25	4.20	4.20	95.0	95.0	97.5	97.5	92.5	92.5
	2.6	4.05	4.10	4.28	4.28	4.15	4.20	85.0	90.0	95.0	95.0	90.0	90.0
	2.7*	4.05	4.18	4.40	4.40	4.30	4.28	85.0	92.5	95.0	95.0	95.0	95.0
	2.9*	4.05	4.25	4.25	4.28	4.28	4.30	85.0	95.0	95.0	97.5	95.0	97.5
	2.11	4.30	4.33	4.30	4.30	4.30	4.30	95.0	97.5	97.5	97.5	92.5	92.5
	2.12	4.13	4.15	4.18	4.18	4.18	4.18	90.0	92.5	95.0	95.0	95.0	95.0
Domain III: assessment skills	3.1	4.25	4.20	4.48	4.53	4.53	4.60	97.5	97.5	100.0	100.0	100.0	100.0
	3.2*	4.15	4.28	4.35	4.38	4.38	4.35	87.5	95.0	97.5	97.5	95.0	95.0
	3.3*	4.13	4.20	4.35	4.38	4.33	4.35	92.5	97.5	95.0	95.0	95.0	97.5
	3.4	4.20	4.20	4.40	4.40	4.43	4.45	97.5	97.5	97.5	97.5	100.0	100.0
	3.5*	4.13	4.23	4.35	4.40	4.23	4.28	92.5	97.5	97.5	97.5	95.0	95.0
	3.7	4.15	4.18	4.38	4.33	4.23	4.23	92.5	95.0	97.5	95.0	92.5	92.5
	3.8	4.15	4.18	4.50	4.50	4.50	4.53	85.0	90.0	100.0	100.0	97.5	100.0
	3.9	4.18	4.23	4.28	4.28	4.28	4.28	90.0	95.0	92.5	95.0	95.0	95.0
Domain IV: analytical and intervention skills	4.1*	3.93	4.08	4.28	4.30	4.45	4.50	77.5	95.0	95.0	95.0	97.5	97.5
	4.4*	4.13	4.23	4.35	4.38	4.40	4.43	85.0	87.5	100.0	100.0	100.0	100.0
	4.5*	4.08	4.18	4.40	4.43	4.45	4.45	82.5	97.5	100.0	100.0	100.0	100.0
	4.8*	4.23	4.23	4.38	4.38	4.38	4.38	92.5	95.0	95.0	95.0	95.0	95.0
	4.10	4.18	4.18	4.23	4.23	4.25	4.28	92.5	87.5	100.0	100.0	100.0	100.0
	4.11	4.08	4.05	4.33	4.33	4.23	4.20	87.5	95.0	100.0	100.0	97.5	97.5
	4.12	4.25	4.25	4.43	4.43	4.45	4.48	95.0	92.5	100.0	100.0	100.0	100.0
	4.13*	4.15	4.25	4.33	4.30	4.38	4.38	90.0	95.0	100.0	97.5	97.5	95.0
	4.14*	4.10	4.20	4.20	4.20	4.25	4.25	92.5	95.0	95.0	95.0	92.5	95.0
	4.15	4.15	4.18	4.43	4.43	4.43	4.43	95.0	100.0	100.0	100.0	100.0	100.0
Domain V: communication skills and teamwork	5.1	4.33	4.38	4.53	4.60	4.58	4.58	95.0	100.0	97.5	100.0	100.0	100.0
	5.3*	3.88	4.00	4.20	4.28	4.38	4.40	77.5	87.5	92.5	95.0	95.0	95.0
	5.4	4.10	4.10	4.30	4.33	4.40	4.40	87.5	97.5	95.0	100.0	97.5	97.5
	5.5	4.28	4.28	4.35	4.38	4.45	4.45	97.5	97.5	95.0	97.5	97.5	97.5
	5.6	4.30	4.30	4.35	4.35	4.43	4.45	97.5	95.0	100.0	100.0	100.0	100.0
	5.7	4.23	4.23	4.25	4.25	4.35	4.35	95.0	90.0	95.0	95.0	95.0	95.0
	5.8	4.15	4.15	4.33	4.35	4.40	4.38	90.0	92.5	95.0	97.5	95.0	95.0
	5.9	4.13	4.20	4.35	4.35	4.38	4.35	90.0	92.5	97.5	97.5	97.5	97.5
Domain VI: advocacy	6.1	4.10	4.08	4.25	4.28	4.30	4.30	90.0	97.5	95.0	95.0	97.5	97.5
	6.4	4.20	4.20	4.18	4.23	4.18	4.18	97.5	97.5	97.5	97.5	92.5	92.5
	6.5	4.25	4.25	4.30	4.33	4.35	4.30	97.5	90.0	100.0	100.0	100.0	100.0
Maybe items—need further discussion: 2nd agreement of relevance < 95
Domain I: overarching values	1.5*	4.05	4.28	4.25	4.28	4.28	4.35	87.5	95.0	92.5	92.5	97.5	97.5
Domain II: knowledge of long-term care and case management practice	2.3	4.08	4.10	4.23	4.23	4.18	4.15	85.0	87.5	90.0	90.0	90.0	90.0
	2.14	4.13	4.13	4.10	4.08	4.00	4.00	90.0	90.0	95.0	92.5	85.0	85.0
Domain III: assessment skills	3.6	4.08	4.08	4.18	4.18	4.20	4.20	87.5	87.5	90.0	90.0	90.0	90.0
Domain IV: analytical and intervention skills	4.2	4.18	4.15	4.23	4.23	4.35	4.35	92.5	95.0	92.5	92.5	95.0	95.0
	4.9*	4.08	4.23	4.35	4.35	4.40	4.43	85.0	92.5	92.5	92.5	92.5	92.5
Domain V: communication skills and teamwork	5.10	4.13	4.15	4.25	4.28	4.18	4.23	90.0	87.5	90.0	92.5	90.0	90.0
Domain VI: advocacy	6.2	4.20	4.23	4.00	4.00	4.10	4.08	95.0	92.5	85.0	87.5	92.5	90.0
Excluded items: mean < 4 or agreement < 85 in one or more aspects (bolded values indicate failure to meet the inclusion criteria.)
Domain I: overarching values	1.3*	3.83	3.93	4.18	4.23	4.35	4.45	72.5	80.0	90.0	95.0	90.0	95.0
Domain II: knowledge of long-term care and case management practice	2.5*	3.93	4.10	4.10	4.15	4.00	4.05	72.5	82.5	90.0	90.0	85.0	85.0
	2.8	4.08	4.08	4.05	4.08	4.03	4.03	87.5	87.5	87.5	87.5	82.5	82.5
	2.10	4.10	4.10	4.15	4.13	4.05	4.03	82.5	80.0	95.0	92.5	92.5	90.0
	2.13*	4.00	4.05	3.93	3.90	4.05	4.05	85.0	90.0	77.5	75.0	82.5	80.0
Domain IV: analytical and intervention skills	4.3*	4.13	4.25	4.13	4.05	4.18	4.20	90.0	87.5	87.5	82.5	87.5	87.5
	4.6	4.33	4.33	4.43	4.43	4.48	4.48	97.5	67.5	95.0	95.0	100.0	100.0
	4.7*	3.88	3.78	4.13	4.10	4.28	4.28	77.5	92.5	87.5	85.0	87.5	87.5
Domain V: communication skills and teamwork	5.2	4.25	4.30	4.33	4.38	4.43	4.45	95.0	82.5	97.5	97.5	97.5	97.5
Domain VI: advocacy	6.3	4.18	4.15	3.98	3.95	3.90	3.88	95.0	97.5	80.0	80.0	80.0	77.5

Eleven of the 59 items had relatively low clarity scores. Dissent regarding the clarity of these statements indicated ambiguity in interpretation or wording, necessitating revision to make them easily understandable. Therefore, based on 74 statements of feedback and suggestions from experts, 23 item statements were revised. This included items with a mean score of less than 4.20 and at least one suggested revision, or items that received two or more comments expressing concerns or suggestions for amendments.

Second consensus questionnaire survey

All 40 panelists who completed the first survey also completed the second-round questionnaire. When comparing the results of the two rounds, 21 of the 23 revised items received higher mean scores and a higher percentage agreement regarding clarity.

After synthesizing the results of the second-round ratings, 10 of the 59 items were excluded due to failure to reach consensus in one or more aspects (clarity, relevance, or importance). Among the 10 items, six were primarily excluded because their clarity ratings did not meet the consensus threshold, while the remaining items scored relatively low in either relevance or importance. Notably, three items related to assistive technology (Item 2.5 on understanding assistive technology products, Item 4.3 on guiding older adults and caregivers in choosing assistive devices, and Item 6.3 on promoting innovative practices in technology-enabled services) were all excluded from the framework. Qualitative analysis of open-text responses showed that experts generally recognized the potential and future importance of gerontechnology in LTC. However, they believed it was premature to include these competencies as core requirements for practitioners at this stage. Several experts noted that these skills should be viewed as “additional” or “advanced” rather than “essential”. Due to limited service resources and uneven technology adoption, incorporating them into core training was seen as impractical. This indicates that experts tend to focus on the most immediate and broadly applicable knowledge and skills for current practice, rather than more future-oriented or specific competencies.

49 items met the consensus criteria across all three aspects, including five in Domain I, 10 in Domain II, nine in Domain III, 12 in Domain IV, nine in Domain V, and four in Domain VI. Consistent with the predefined plan, these consensual items were further differentiated by their relevance ratings. Specifically, 41 items with strong agreement (≥ 95% of respondents affirming relevance) were directly included in the final framework. The remaining eight items, with relevance agreement percentages ranging from 85 to 95%, were set aside for further discussion at a subsequent roundtable meeting. More details can be seen in Table 2 (each item’s interquartile range for all aspects ≤ 1 in two rounds).

Second roundtable discussion

A total of 21 out of 40 panelists participated in this roundtable discussion. These panelists reviewed and confirmed the list of included and excluded items and shared their viewpoints on the pending items. Disagreements regarding these eight items primarily centered around themes such as interdisciplinary collaboration, access to medication-related information, and the application of assessment tools. Following an open discussion, a vote was conducted on the eight remaining items. To ensure all panelists had the chance to participate, the meeting recording and voting link were emailed to those who could not attend. Ultimately, 33 responses were received (representing an 82.4% response rate). The voting results showed that all eight items received support from over 50% of voters. Seven of these items achieved over 75% approval, while Item 6.2 just crossed the inclusion threshold with 54.8% support. Detailed feedback from panelists is presented in the Discussion section. In conclusion, the final competency framework of LTC case management practice featured 49 items (see Fig. 2).

Fig. 2.

Six domains of case management competency framework for long-term care

Third roundtable discussion

At the final roundtable discussion meeting, 27 panelists (67%) participated and approved the finalized list of competencies. Given the diverse roles and responsibilities in the LTC case management team, it is logical that not all LTC workforce members should possess the same level of knowledge and skills. To improve the competency framework for training purposes, panelists were divided into five groups to evaluate and discuss appropriate levels for each competency item. Guided by the distinction between “prerequisite items” (foundational knowledge expected of trainees) and “essential items” (core competencies emphasized in training), each group initially classified the items. The research team then combined the results and assigned a preliminary category to each item based on majority vote. Items with conflicting classifications or that needed further clarification were discussed collectively to reach a consensus. During this process, panelists identified a subset of competencies representing advanced, supervisory skills, especially in leadership and team supervision. This led to the introduction of a third, higher-level category. Ultimately, three progressive levels were developed. The fundamental level, labeled “important competencies for all LTC workers (AIC)”, consisted of six items; the middle level, “most important competencies for case management practice (MIC)”, included 41 items; and the upper level, “foremost important competencies for case management supervision (FIC)”, featured two items. The finalized framework, ratings, and tiers for all items are shown in Table 3.

Table 3.

The final list of competencies and their ratings

Domain	Item no.	Competence statement	Agreement on relevance from the 3rd Delphi round (%)	Agreement on inclusion from the 4th Delphi round (%)	Tier
Domain I: overarching values	1 [1.1]	Understand the principles of case management, adopting a person-centered approach	100.0		AIC
	2 [1.2]	Respectful and empowerment-oriented	97.5		MIC
	3 [1.4]	Coordinate with various stakeholders and build effective partnerships	97.5		MIC
	4 [1.5]	Follow the principle of “Prevention is better than cure”	92.5	97.0	MIC
	5 [1.6]	Adhere to confidentiality guidelines	95.0		MIC
Domain II: knowledge of long-term care and case management practice	6 [2.1]	Familiar with the scope and content of case management	100.0		AIC
	7 [2.2]	Aware of health professionals’ roles in implementing individual care plans	100.0		MIC
	8 [2.3]	Have knowledge of the interRAI assessment suites	90.0	93.3	AIC
	9 [2.4]	Have knowledge of common chronic diseases affecting older adults	97.5		MIC
	10 [2.6]	Possess gerontology knowledge relevant to professional roles and responsibilities	95.0		MIC
	11 [2.7]	Understand the effectiveness of various interventions and their applicability	95.0		MIC
	12 [2.9]	Skilled in identifying resources, pathways, and appropriate timing for referral	97.5		MIC
	13 [2.11]	Familiar with long-term care policy and application procedure in Hong Kong	97.5		MIC
	14 [2.12]	Able to obtain and update information related to case management	95.0		MIC
	15 [2.14]	Know how to use electronic record-sharing systems to search medical and pharmaceutical information	92.5	76.7	MIC
Domain III: assessment skills	16 [3.1]	Understand changes associated with aging and disease progression to conduct a a comprehensive assessment	100.0		MIC
	17 [3.2]	Able to apply proper assessment tools	97.5		AIC
	18 [3.3]	Aware and evaluate the common physical health issues	95.0		MIC
	19 [3.4]	Aware and evaluate the common cognitive and mental issues	97.5		MIC
	20 [3.5]	Aware and evaluate the social support of service users	97.5		MIC
	21 [3.6]	Aware and evaluate the medication use	90.0	90.3	MIC
	22 [3.7]	Develop individualized care plan respecting cultural, spiritual and lifestyle preferences	95.0		MIC
	23 [3.8]	Evaluate the appropriateness of care plans and environment	100.0		MIC
	24 [3.9]	Conduct timely assessments, especially for admission and discharge cases	95.0		MIC
Domain IV: analytical and intervention skills	25 [4.1]	Aware and mitigate the risks of disease-related deterioration and decline of intrinsic capacities	95.0		MIC
	26 [4.2]	Can interpret interRAI and other assessment reports	92.5	96.7	AIC
	27 [4.4]	Strive for a balance between safety, preferences, and intervention outcomes	100.0		MIC
	28 [4.5]	Inquire into family background to inform care plans	100.0		MIC
	29 [4.8]	Develop comprehensive individual care plans considering social and environmental aspects	95.0		MIC
	30 [4.9]	Initiate and implement health promotion plans	92.5	100.0	MIC
	31 [4.10]	Suggest appropriate care arrangements based on the family’s economic status	100.0		MIC
	32 [4.11]	Develop a contingency care plan with interdisciplinary support	100.0		MIC
	33 [4.12]	Able to identify and handle high-risk cases	100.0		MIC
	34 [4.13]	Able to multitask and prioritize tasks	97.5		MIC
	35 [4.14]	Provide direct services such as counseling	95.0		MIC
	36 [4.15]	Leverage community services and resources	100.0		MIC
Domain V: communication skills and teamwork	37 [5.1]	Communicate and reach a consensus on care goal setting with the service users and their caregivers	100.0		AIC
	38 [5.3]	Have coping strategies to communicate with service users with impairment and their caregivers	95.0		MIC
	39 [5.4]	Discuss risks to safety and quality of care with the team and users	100.0		MIC
	40 [5.5]	Co-design and co-implement the care plan with service users	97.5		MIC
	41 [5.6]	Promote the participation and involvement of stakeholders	100.0		MIC
	42 [5.7]	Actively liaise with the interdisciplinary team to enhance the service users’ independence and quality of life	95.0		MIC
	43 [5.8]	Supervise the implementation of individual care plans	97.5		FIC
	44 [5.9]	Lead the team to implement the individual care plans	97.5		FIC
	45 [5.10]	Participate in case meetings within the interdisciplinary team	92.5	87.5	MIC
Domain VI: advocacy	46 [6.1]	Enhance evidence-based case management practice	95.0		MIC
	47 [6.2]	Participate in case management research	87.5	54.8	MIC
	48 [6.4]	Advocate improvement on community resources and policy	97.5		MIC
	49 [6.5]	Continuously contribute to the advancement of case management models	100.0		MIC

The three competency tiers are hierarchically structured. AIC = important competencies for all long-term care workers (fundamental level); MIC = most important competencies for case management practice (middle level); FIC = foremost important competencies for case management supervision (upper level)

Discussion

In this study, we employed a robust five-round participatory Delphi method to develop a comprehensive transdisciplinary competency framework. This framework aligns with the WHO’s advocacy in the action area of LTC and is specifically designed to enhance the competencies and professionalism of LTC workers. The framework also facilitates more targeted applications in real-world case management scenarios globally.

The final competency framework featured 49 competencies organized into six domains, based on high consensus among experts. These competencies include a fundamental understanding of core values and knowledge, advanced skills in assessment and intervention, and the promotion of teamwork and advocacy. The development of this framework involved a thorough and dynamic process. Based on guidance from Batt and colleagues [34], the research team and expert panel conducted several rounds of discussion and voting to clarify the scope, detail, and context of the framework, given the complexity and diversity of LTC case management services.

This framework not only encompasses the necessary knowledge and skills for professional practice [35], but also emphasizes the importance of values. It is firmly grounded in the core principles that underpin effective long-term care systems. According to the WHO’s guidance for achieving an integrated continuum of long-term care, robust LTC systems should be anchored by three principles: person-centeredness; equity, affordability, accessibility; and respect for human rights and dignity [3]. Our framework operationalizes these principles at the individual practitioner level, translating them into tangible competencies that collectively drive system-level transformation. The principle of person-centeredness serves as the foundational entry point (Item 1.1) and permeates the framework [36]. It manifests in empowerment-oriented practice (Item 1.2), individualized care plans respecting cultural and lifestyle preferences (Item 3.7), and collaborative decision-making that ensures service users remain active partners in their care journey (Items 5.1, 5.5). The principle of equity, affordability, and accessibility is reflected in competencies that leverage community resources (Item 4.15), consider families’ economic status (Item 4.10), and advocate for systemic improvements (Item 6.4). Finally, the commitment to human rights and dignity is embedded in requirements for respectful practice (Item 1.2), confidentiality (Item 1.6), and safeguarding vulnerable individuals (Item 4.12). In essence, this framework translates WHO’s system-level principles into an actionable blueprint, ensuring that every aspect of LTC case management is guided by person-centered, equitable, and dignified care.

Beyond operationalizing these key values, this competency framework underscores the essential nature of interdisciplinary collaboration [37], making it particularly suited for case management responsibilities. By integrating knowledge and competencies across various disciplines, this transdisciplinary framework distinguishes itself from profession-specific models [11]. It provides cohesive and holistic guidance for a diverse range of health and social care professionals involved in LTC case management [12]. Previous studies have identified principles of effective interdisciplinary collaboration, including the integration of team members’ skills and personalities, the clarification of values, and the promotion of communication and coordination [10]. These principles are all reflected in this transdisciplinary competency framework, which provides guidance for high-level functioning of case management teams. Furthermore, this framework facilitates the connection of micro-level services with macro-level policy improvements by highlighting advocacy [37–40], thereby enhancing the aging friendliness of the social environment and promoting the sustainable development of LTC.

During several rounds of scoring and discussion voting, consensus on some competencies regarding relevance and necessity was less consistent compared with other items. The most contentious issue was whether case management practitioners should participate in related research projects (Item 6.2). Some panelists argued that the main task of professionals is to provide services, and assisting with research should not be considered a necessary skill. Others emphasized that the integration of practice and research is crucial for the sustainable development of the LTC profession [41]. Including research capabilities in the competency framework can encourage practitioners to strengthen their collaboration with academia and promote more translational research [42].

The relatively low ranking of “Participate in case meetings within the interdisciplinary team” (Item 5.10) highlights the need to strengthen interdisciplinary collaboration and mutual learning. Scholars have recognized that close collaboration among experts from different disciplines in case management services is essential for improving service quality and efficiency [43]. Existing research has emphasized the significant role of team meetings in promoting effective interdisciplinary teamwork. These meetings help enhance communication among professionals, facilitate information sharing and shared decision-making, and resolve conflicts between team members to reach consensus [44]. Moreover, incorporating the client and their family members into interdisciplinary meetings is believed to further enhance person-centered care [45].

Additionally, the ranking for obtaining and comprehending information on medication use (Items 2.14 and 3.6) was relatively lower compared with other aspects. Some panelists pointed out that assisting older adults with medication management is an essential part of case management, while others also acknowledged that medication use primarily falls in the professional domain of physicians and pharmacists, who are currently not typically part of case management teams in Hong Kong. This finding is consistent with a previous study that found some healthcare professional groups reached less consensus about the roles and competencies involved in managing polypharmacy [46]. However, recent editorials on interdisciplinary LTC teams suggest that promoting transdisciplinary learning among team members is essential, enabling them to understand and respect the knowledge and skills from different disciplines [9]. Therefore, enhancing frontline case workers’ training on medication-related issues is an inevitable trend.

It is worth noting that the two interRAI-related items (Items 2.3 and 4.2) were classified as pending based on their comparatively lower outcomes regarding relevance in two rounds of consensus voting. InterRAI is a third-generation comprehensive geriatric assessment tool that can be used across care settings and enables a collaborative approach for professionals from various disciplines through the same protocol [47]. The results of the interRAI assessment can help with care planning, measuring outcomes, improving quality, and allocating resources [48]. However, the use of interRAI remains limited, which may be attributed to challenges such as technical issues, insufficient training, and management adjustments [49]. Reliable and standardized assessment results are essential for teamwork among different disciplines [10]. Therefore, it is important to share the benefits of interRAI and discuss implementation experiences with stakeholders.

Subsequent training curricula can be developed based on this competency framework. In the field of LTC, practitioners’ skill development should align with their career stage—entry level, intermediate, and advanced—with each requiring different proficiency levels [50]. All LTC workers should master six foundational capabilities, which constitute the core content of our basic training curriculum. These six competencies create an integrated pathway aligned with the person-centered approach. The journey begins with practitioners adopting the core values of case management (1.1), emphasizing person-centered care, respect for autonomy and dignity. Building on this value foundation, practitioners need to understand the case management process (2.1) and be familiar with assessment tools like interRAI (2.3). These tools are not the goal but methods to comprehensively understand service users [3], allowing practitioners to apply assessments (3.2) and interpret their results meaningfully (4.2). Ultimately, assessment outcomes must be communicated to the service user, requiring practitioners to engage in dialogue and reach consensus with service users and caregivers on care goals (5.1). This approach promotes co-developed care plans that combine professional expertise with the service user’s voice. In summary, these six competencies serve as the basic logic of case management: values drive assessment, assessment fosters understanding, and collaborative communication keeps the service user at the center.

Moreover, 41 of the other 43 capabilities have been incorporated into intermediate courses designed for key members of case management teams to ensure they can address more complex issues in LTC practice. Furthermore, the abilities outlined in Items 5.8 and 5.9 (Supervise and lead the team to implement individual care plans) are particularly suitable for advanced course development for team supervisors, to enhance their leadership and coordination skills.

Our study had several advantages. First, we adopted a participatory Delphi method that extensively involved experts from various disciplines in LTC services. This ensured a diverse and comprehensive range of perspectives on our expert panel. Second, during the COVID-19 pandemic, we successfully conducted five stages of the Delphi method online, ensuring a timely and orderly process. This significantly increased participation and retention, with a 100% response rate in the first three rounds and a 67% response rate in the final round. Additionally, we set a high threshold for consensus, requiring agreement of 85% or greater, making the final competency framework more precise and instructive.

This study has some limitations. First, the expert panel mainly consisted of social workers, mirroring the current setup of case management teams in Hong Kong’s SWD-managed LTC system, where social workers are key members. While this composition ensured practical relevance to the local context, it also highlights the need for stronger collaboration between healthcare and social work professionals in future workforce development. Second, all participating experts were from Hong Kong. Although the panel included diverse professional backgrounds, the absence of international perspectives may limit the direct applicability of the framework to other health and social care systems.

Despite these limitations, the competency framework proposed in this study demonstrates strong transferability and global relevance. First, the core contribution of the framework lies in proposing a transdisciplinary competency model organized around six key domains. These domains transcend profession-specific knowledge and focus on the common and collaborative competencies essential to case management in LTC settings. Consequently, the framework provides a flexible foundation that can be tailored and expanded by other regions based on their local service configurations and professional scopes of practice. Second, for regions where long-term care case management services are still in the early stages of development, or where professional resources (such as physicians) are limited, this framework offers a clear practical pathway for capacity building among LTC workers. The three-stage competency progression model proposed in the framework also provides explicit guidance for the design of interdisciplinary training programs and the professional development of practitioners. Furthermore, Hong Kong is one of the most rapidly aging societies globally, and its long-term care system has evolved in alignment with internationally recognized assessment tools and service standards. Therefore, the competency framework developed in this context offers valuable insights for other societies facing similar challenges of population aging.

This study has important implications for both policy and practice. With the proposed framework, policymakers can facilitate transdisciplinary case management model development by working with stakeholders to determine the resources required to meet the needs of clients and service providers. This competency framework also offers valuable guidance for interdisciplinary collaboration among practitioners at the practice level. It also standardizes the requirements for professional supervision and training. Additionally, the different levels of competency expectations provide clear direction for individual practitioners’ professional development.

Conclusion

In conclusion, this study developed a transdisciplinary case management competency framework comprising 49 competencies across six domains, using a participatory Delphi approach. The framework reflects a paradigm shift from interdisciplinary collaboration toward a truly transdisciplinary approach to workforce development. It is applicable to professionals from various disciplines engaged in LTC case management practice. By integrating knowledge and competencies across health and social care professions, the framework fosters a unified professional identity for case management teams that transcends disciplinary boundaries. This integration ensures that older adults receive coherent, comprehensive care from specialized interdisciplinary teams equipped to address their complex and evolving needs. We further stratified these competencies into three progressive levels—entry-level, intermediate, and advanced. These tiers provide practitioners with a clear developmental pathway, empowering professionals at all stages to become effective agents of high-quality LTC services.

Furthermore, the framework operationalizes the WHO’s core principles for LTC systems into concrete competency requirements at the individual practitioner level. These requirements ensure that every care plan and every interdisciplinary collaboration are guided by a commitment to dignity and person-centeredness. In this study, person-centered care serves as both the foundation of the framework and a thread woven throughout the co-design and co-implementation of individualized care plans. Competencies for all LTC workers emphasize the active participation of older adults and their caregivers, ensuring that older adults remain engaged partners throughout their care journey. In an increasingly aging world, this framework offers a promising blueprint for building a workforce capable of delivering the integrated, respectful, and empowering care that every older adult deserves.

Abbreviations

CMP

Case Management Practice

LTC

Long-term care

WHO

World Health Organization

SWD

Social Welfare Department

HA

Hospital Authority

Author contributions

YH: writing—original draft, writing—review and editing, visualization, methodology, formal analysis. NX: writing—original draft, writing—review and editing, conceptualization. VWL: writing—review and editing, supervision, funding acquisition, resources, conceptualization, project administration. YZ: writing—review and editing, data curation, investigation, methodology. All authors have approved the final version of the manuscript.

Funding

This work was supported by the Hong Kong Jockey Club Charities Trust [Grant No. 2021-0256].

Availability of data and materials

The original data contributions in this study are shown in this manuscript. For additional inquiries, please contact the corresponding author.

Declarations

Ethics approval and consent to participate

Ethical approval of this study was granted by the Hong Kong University Human Research Ethics Committee (Ref: EA220362).

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.