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.). 

References:

Definition and philosophy of case management . (2018). Retrieved from https://ccmcertification.org/about-ccmc/about-case-management/definition-and-philosophy-case-management

eHealth Initiative and Foundation website. (2015). https://www.ehidc.org/

Nursing excellence. (n.d.). Retrieved from https://www.nursingworld.org/practice-policy/nursing-excellence/