Scope of the Problem
Many people who live with serious illnesses are
increasingly cared for in community settings. Care of such people often includes
gaps in care coordination. Case management is a cooperative process that includes assessment,
planning, implementation, coordination, and evaluation of services necessary to
address a client’s health needs. The primary principle is that clients benefit
when they reach their highest level of wellness, self-management, and functional
ability ("Definition of case
management," 2018). It requires
the case manager to advocate, communicate, and manage resources while promoting
timely, safe, and cost-effective care and outcomes. The case manager links patients with appropriate
providers and resources to ensure safe, effective transition of care after
discharge. Fragmentation of resource information makes it difficult to access
and use the plethora of data needed to give high-quality post discharge care. This is a barrier to
providing effective case management. Current
practice relies on general knowledge, folders of paper information, peer collaboration, and research. The various community resources available each
has its own criteria for patient eligibility. It can take an extraordinary amount of time to
sift through available community resources available to a particular patient considering
their geographic location, insurance, age, physical and/or psychological needs,
and post acute-care discharge needs.
Solution Proposal
A potential solution to resolution of the identified barrier is to
utilize an application for mobile devices in which local community resources
are arranged and categorized by their qualifying criteria with which case
managers could quickly and easily access to identify appropriate resources for
a given patient. This would allow
integration of disparate data to enhance operational efficiencies. Case managers would access the app on their
mobile device, enter patient data in real-time and have resulting collation of matching
community resources. Of course,
implementing new technology in any field can be challenging as it can
temporarily disrupt workflow. Differing
levels of technical skills and comfort with technology among staff are to be
expected. Health information technology (HIT)
is becoming key to gathering and exchanging data. Some organizations are leveraging complex HIT
systems to “digitize the data collection process and aggregate data from
multiple sources in to a centralized location” (eHealth Initiative and Foundation
website, 2015, p. 3). Rather than meeting
with a patient and then returning to the office to document and research
community resources, it allows the case managers to be more mobile.
Design of this app would require collaboration among experienced
case managers and information technology personnel. Determining criteria must be identified and kept
as simple as possible to enhance ease of use. Some criteria that may be applicable could
include the patient’s age, zip code, insurance, and physical and/or psychological need. A comprehensive list of current community
resources would be needed. The app would
need to be capable of being updated as community resources change to remain
current. Each resource on the app would
have correlating contact information.
Benefits and Limitations
Case managers utilize information from multiple sources to successfully
meet their patients’ needs. A thorough
case management app that can manage diverse community resources and their
criteria expands the case manager’s ability to manage each individual patient’s
plan for transition after discharge. This can lead to more time with patients and
less time spent researching and sifting through paper resources. Having information regarding available community
resources in one place which is easily accessible in real-time would enhance
efficiency and improve patient outcomes by increasing potential links for
patients to the resources they need while decreasing time to find the “right
one” and diminishing risk of missing a possible resource. When a patient is not connected with
appropriate resources, it can increase chance of readmission and missed care. A limitation of this app is patients who
do not live in locally to the facility.
1. Technology: Is the app user friendly? Is it easy to
maneuver? Can it be easily updated with new resources without undue costs or
loss of functionality?
2. Improving outcomes: How would using this app improve
your patient’s outcomes?
3. Practice: How would using an app like this improve or enhance your practice?
That’s a WrAPP
It’s most likely that
technology in case management is here to stay.
As technology improves and becomes more prevalent, the aspects and expectations
for case management will continue to change and grow. The American Nurses Association (ANA) believes
that patients’ welfares are best served by collaboration of health care
professionals to deliver safe, effective, and affordable care to address the
intricacies of modern health care and while giving reliably exceptional care ("Nursing Excellence," n.d.).
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