Evaluating case management as a complex intervention: Lessons for the future

Der klinische Versorgungspfad zur multiprofessionellen Versorgung seltener Erkrankungen in der Pädiatrie – Ergebnisse aus dem Projekt TRANSLATE-NAMSE

Hintergrund

Seltene Erkrankungen (SE) manifestieren sich ganz überwiegend im Kindes- und Jugendalter, sind heterogen, multisystemisch, haben meist einen chronischen Verlauf und stellen eine große Herausforderung für alle Beteiligten dar. Finanziert durch den Innovationsfonds des G‑BA hatte das Versorgungsprojekt TRANSLATE-NAMSE das Ziel, Vorschläge zur besseren Versorgung von Menschen mit SE zu entwickeln und zu erproben.

Fragestellung

Für Patienten aller Altersgruppen mit einer Verdachtsdiagnose aus einer von 5 Gruppen definierter Indikatorerkrankungen (seltene Anämien, Endokrinopathien, Autoinflammationserkrankungen, primäre Immundefekte und Stoffwechselerkrankungen) sollte ein generischer Versorgungspfad entwickelt werden, der den Weg von der Konfirmationsdiagnostik bis hin zur Langzeitbetreuung dieser Patienten abbildet.

Methodik

Der Versorgungspfad wurde als allgemeines Ablaufschema dargelegt; die Prozessschritte wurden in eine Checkliste übertragen, inhaltlich ausformuliert und an 6 universitären Standorten an 587 Personen mit der Verdachtsdiagnose einer Indikatorerkrankungen erprobt.

Ergebnisse

Für 369 (62,9 %) Fälle mit der Verdachtsdiagnose einer Indikatorerkrankung konnte eine Diagnose gestellt werden, davon in 25,2 % mit innovativer genetischer Diagnostik; 104 (17,7 %) Verdachtsdiagnosen erwiesen sich als falsch-positiv; 114 (19,4 %) Fälle blieben ungeklärt. An Fallkonferenzen zur multiprofessionellen Versorgung nahmen im Median 4 Spezialisten teil. Die Versorgung (Diagnoseeröffnung, Schulung, Beratung, Information) begann im Median am Tag des Diagnostikergebnisses. In einer externen Evaluation erwies sich die Zufriedenheit der Sorgeberechtigten mit dem Versorgungspfad als hoch.

Schlussfolgerungen

Im bisher in Deutschland einzigartigen TRANSLATE-NAMSE-Projekt wurde ein Versorgungspfad für SE in der Pädiatrie entwickelt und erfolgreich erprobt. Zur Verstetigung dieser Versorgungsform ist eine auskömmliche Finanzierung in der Regelversorgung anzustreben.

An Integrated clinical pathway for diagnosis, treatment and care of rare diseases: model, operating procedures, and results of the project TRANSLATE-NAMSE funded by the German Federal Joint Committee

BACKGROUND

Diagnosis, treatment, and care of patients with rare diseases require multidisciplinary cooperation between medical and paramedical specialities and with patients and families. Innovative genetic diagnostics, whole exome and whole genome sequencing (WES, WGS) has enlarged the diagnostic toolkit but also increased the complexity of the endeavour. Structured multidisciplinary clinical pathways (CPW) can guide diagnosis, treatment, and care of patients with rare diseases, link scientific evidence to clinical practice and optimise clinical outcomes whilst maximising clinical efficiency.

RESULTS

In contrast to the common approach of appending disease-specific CPWs to disease-specific guidelines, we suggest a generic CPW manoeuvring the patient along the way of finding the correct diagnosis by applying the best diagnostic strategy into an appropriate system of treatment and care. Available guidelines can be integrated into the generic CPW in the course of its application. The approach also applies to situations where a diagnosis remains unsolved. The backbone of the generic CPW is a set of multidisciplinary structured case conferences projecting and evaluating diagnostic and/or therapeutic steps, enforcing to integrate best scientific evidence with clinical experience. The generic CPW is stated as a flowchart and a checklist which can be used to record and document parsimoniously the structure, process and results of a patient's pathway, but also as a data model for research. It was applied in a multicentre setting with 587 cases each with a presumptive diagnosis of a rare disease. In 369 cases (62.8%) a diagnosis could be confirmed, and multidisciplinary treatment and/or care was initiated. The median process time from first contact until confirmation of diagnosis by WES was 109 days and much shorter than diagnostic delays reported in the literature. Application of the CPW is illustrated by two case reports.

CONCLUSIONS

Our model is a tool to change the diagnostic odyssey into an organised and trackable route. It can also be used to inform patients and families about the stages of their individual route, to update health care providers only partially involved or attending specialised treatment and care, like the patient's or family's primary physician, and finally to train novices in the field.

What Makes Integration of Chronic Care so Difficult? A Macro-Level Analysis of Barriers and Facilitators in Belgium

Introduction

Although many countries have been implementing integrated care, the scale-up remains difficult. Macro-level system barriers play an important role. By selecting three key policies, which have implemented integrated care in Belgium over the last 10 years, we aim to go beyond the identification of their specific barriers and facilitators to obtain an overarching generic view.

Methods

27 participants were purposefully selected, to include all important stakeholders involved on the macro-level in chronic care in Belgium. Semi-structured interviews were guided by a timeline of policies and an inductive thematic analysis was performed.

Results

Barriers and facilitators were identified on both health care and policy level. The major factors restraining the scale-up of integrated care are the fee-for-service reimbursement system, limited data sharing and the fragmentation of responsibilities between different levels of government. Remarkably, these factors strongly interact.

Discussion

This paper highlights the importance of homogenization of responsibilities of governments regarding integrated care and the interdependency of policy and health care system factors. A whole system change is needed instead of the current Belgian model of prolonged search for common ground between conflicting opinions. Political commitment and citizen participation will be crucial.

Application Effect of Case Management Mode Combined with ERAS in Elderly Patients with Hip Fracture

Objective

To explore the effect of the case management mode combined with enhanced recovery after surgery (ERAS) in elderly patients with hip fracture.

Methods

A total of 102 elderly hip fracture patients admitted to our hospital from June 2018 to December 2019 were selected. The patients with hip fracture were divided into the control group (n = 51) and the observation group (n = 51) by the random number table method. The control group adopts the conventional nursing mode, and the observation group adopts the case management mode combined with ERAS. The bed activity time, hospitalization time, total hospitalization expenses, and the satisfaction of patients were observed. The numeric rating scale (NRS) was used to assess the patient's pain before treatment and at 1, 3, and 5 days after treatment. The Harris score was used to assess the patient's joint motor function before treatment and at the 8th week after treatment. The perioperative complications of the two groups were compared.

Result

After treatment, the observation group was better than the control group in terms of out of bed activity time, hospitalization time, total hospitalization expenses, and the satisfaction of patients (P < 0.05). Before treatment, there was no significant difference in NRS scores between the two groups (P > 0.05). After treatment, the NRS scores of the two groups were lower than before treatment, and on days 1, 3, and 5 after treatment, the NRS scores of the observation group were lower than those of the control group (P < 0.05). Before treatment, there was no difference in the Harris score between the two groups (P > 0.05). At the 8th week after treatment, the Harris scores of the two groups were higher than those before treatment, and the Harris scores of the observation group were higher than those of the control group (P < 0.05). The total incidence of perioperative complications in the observation group (4/51) was lower than that in the control group (13/51) (P < 0.05).

Conclusion

The application of the case management mode combined with ERAS nursing in elderly patients with hip fracture can improve the clinical symptoms of patients, improve the therapeutic effect, and reduce the occurrence of complications, which is worthy of clinical application.

An Evaluation of the Use and Effectiveness of Case Management in Clinical Nursing Education

Background

This study aims to evaluate the use and effectiveness of case management in clinical nursing education.

Methods

A sample of 181 nurses at the N3–N5 level were selected for clinical nursing education and divided into two groups using the random number method. The control group (n = 90) received traditional training, and the observation group (n = 91) received a case management model of training. The theoretical knowledge, nursing skills, training satisfaction, job stress, workplace mindfulness, career satisfaction, and job happiness of the two groups were compared. In addition, 50 patients were selected as subjects for each group, and their satisfaction with the nursing care that they received was also measured and compared.

Results

Theoretical knowledge and nursing skills scored higher in the observation group than in the control group (p < 0.05), and overall training satisfaction was higher in the observation group than in the control group (p < 0.05). After training, job stress in the observation group was lower than in the control group (p < 0.05), while workplace mindfulness, career satisfaction, and job happiness were higher in the observation group than in the control group (p < 0.05). In terms of nursing quality, on all indicators, the observation group scored higher than the control group (p < 0.05), and the patients’ nursing satisfaction scores were higher in the observation group than in the control group (p < 0.05).

Conclusion

Case management can improve the professionalism and overall skills of nurses at the N3–N5 levels. It is conducive to reducing job stress, enhancing workplace mindfulness, improving career satisfaction and job happiness, and improving the quality of nursing, thereby providing patients with better nursing care.

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

Case management (CM) is an integrated care strategy, characterised by a set of actions to support person-centred planning, coordination of health and social services. Decades of CM, organisational psychology and occupational research highlight how vagueness and ambiguity in role communication can create role conflict and job stress, negatively impacts staff turnover, intra-organisational collaboration, job performance, and that poor communication of CM impedes policy, quality analysis service development and practice. We conducted a detailed top-down hierarchical, quality analysis of communication about CM roles and responsibilities in a Scheme for people with disability in Australia. The study used content analysis methods and the main actions as defined in a validated CM taxonomy (Appendix 1). We systematically searched and analysed 53 Scheme policy and practice documents of CM from 2013-2019. The results showed poor role communication with vagueness, ambiguity, gaps in the description of CM roles and responsibilities. Poor role communication has contributed to negative experiences and outcomes of CM actions of planning and coordination, as reported by CM users in many Scheme-related parliamentary inquiries, research, formal complaints, and decision appeals. The results reinforce the importance of an ontological approach in communication of CM roles and actions and provides learnings for integrated care roles across countries and contexts.

The direct cost of disability of community-dwelling older persons in Belgium

Current policies aim to promote and develop community-based support of disabled elderly persons, yet knowledge of the cost implications is insufficient. Thus, we aimed to estimate, for three disability profiles and three presence levels of the main informal carer (none, non-cohabitant, cohabitant), the cost of formal and informal support currently provided at home in Belgium. In this cross-sectional study, a sample of 5,642 disabled elderly persons living at home was established between 2010 and 2016. The administrative database of the Belgian public healthcare insurance was merged with other prospective data on social care service utilisation, informal care and disability. The total cost of formal support ranged from €725 to €1,344 (on average, per person, per month), depending on the three disability profiles identified. Twenty-five per cent of persons with the highest level of disability (important functional limitations and cognitive impairment) and helped by a cohabitant carer, had a low total cost of formal support: below €382 per month. Informal care represented the main cost component of total support costs in the three disability profiles (between 64 and 76%). To prevent the worsening of situations of disabled older persons and their informal carers, better detection of seriously disabled persons with low levels of formal support is crucial.