Tracking System for Complex

Care
Authors: Jessica Oh & Kylie Newman, VALORS (2017)
Identified Problem

 Psych: Observed recurrent relapse, return to hospital for

same needs. “Revolving door.”
 Head and Neck Cancer: This diagnosis entails
care/treatment that can be extremely complex. A lot of
departments get involved and things are often on a
time-clock as providers follow evidence-based
treatment plans recommended by various cancer
organizations. Veterans often become confused and
frustrated regarding what their next step is and how to
get there. There exists a significant percentage of
patients who are “slipping through the cracks.”
 Current State

 Psych: Case management mainly in the hands of

social workers or psychiatrists. The psychiatrists meets
up with the patients and discusses the follow up
appointments/education (Arkansas Psychological
Association, 2017).
 Cancer: There exists huge teams of health care
providers that all play a role in case management,
however, they are not always on the same page.
Right now there are individuals who monitor hepatic
and lung cancers as well as in hemoncology.
SAVAHCS also has a cancer committee headed by
Dr. Maegawa.
 Patients “slip through the cracks” when it comes to
care coordination.
Possible Causes

 According to Moos (2006) and Kassani, Niazi, Hassanzadeh, & Medati (2015) possible
causes include:
 Complex care
 Difficult diagnoses
 Expenses (low socioeconomic status)
 Lack of knowledge
 Life stressors
 Lack of communication between health team members
 Lack of coordination between specialties
 Fragmented health care system
Ideal/Target State

 Patients receive proper follow-up, treatments, etc. without “slipping through

the cracks.”
 Patients are not admitted frequently for the same issues over and over.
 Patients will experience an improved quality of life.
 Improved knowledge about patients’ disease process, preventative
interventions, etc.
 Increased education provided by health care professionals.
 Educate patients on each departments role in their care so they know
where to go if questions arise.
Possible Solutions (Future State)

 Common template for facilities/units to utilize in order for the whole health team to be on
the same page.
 Improve education provided to patients.
 Disperse the responsibility of case management within the care team so that it does not
rely so heavily on just one individual.
 Implement case management for 12 months (or less depending on diagnosis)
 What is case management? What is its
role in health care?

 “Case management is a collaborative process of

assessment, planning, facilitation, care coordination,
evaluation, and advocacy for options and services
to meet an individual’s and family’s comprehensive
health needs through communication and available
resources to promote quality cost-effective
outcomes.”
 -Case Management Society of America
Nurses’ Role in Case Managment

 All nurses on some level are responsible for coordinating

long-term care for their patients. Their goal is to treat their
patients at optimal times in order to keep them healthy
and out of the hospital. (Standards of Practice for Case
Management)
 Per the Nursing Code of Ethics, nurses are held
accountable for advocating for their patients and
providing high quality client care.
 Since a nurse’s role is quite dynamic, they are able to
effectively collaborate with all members of the
interdisciplinary team and facilitate effective care
coordination.
Template Example
Insights from Literature Review

1. Effects of a case management program on patients with oral precancerous lesions: a

randomized controlled trial
2. Long-term effects of a collaborative care intervention on process of care in family
practices in Germany: a 24-month follow-up study of a cluster randomized controlled trial
3. Standards of Practice from the Case Management Society of America
4. For follow-up treatment, including the family decreases the likelihood of relapse (Kassani,
Niazi, Hassanzadeh, & Mendati, 2015)
5. Individuals who obtained help or who sought help were more likely to achieve 3-year
remission and were less likely to relapse. The patients consumed less alcohol and gained
more self-efficacy (Moos, 2006)
Potential Impact

 Improved patient outcomes

 Increased preventative measures implemented
 Improved patient satisfaction
 The potential impact could be measured through a qualitative experiment. In this
experiment, the researcher could have randomized groups (experiment and controlled
groups). Questionnaires would be available after a certain amount of time regarding their
experience with or without continuous care management/tracking.
Recommendations for future
review/action

 Implement template in other units/clinics

 Make electronic template more accessible
Question? Comments?
References

Kassani, A., Niaz, M., Hassanzadeh, J., & Menati, R. (2015). Survival analysis of drug abuse
relapse in addiction treatment centers. Internation Journal of High Risk Behaviors &
Addiction, 4, 3. doi:10.5812/ijhrba.23402
Moos, R. H. (2006). Rates and predictors of relapse after natural and treated remission from
alcohol use disorders. Addiction Journal, 101, 212-222. doi:10.1111/j.360-0443.2006.01310.x