Abstract
Case management is defined as a collaborative process of assessment, planning, facilitation and advocacy for options and services to meet an individual’s holistic needs through communication and available resources to promote quality cost-effective outcomes.
The authors present a Case Management Program that was implemented in 2017 in a Local Health Unit to respond to chronic patients and health services overusers, in order to guarantee a better quality of care and management of their clinical and social problems, reducing emergency service episodes and avoidable hospitalizations. The Case Manager is a Primary Health Care nurse, part of a multidisciplinary team consisting in doctors (Internal Medicine and Family Medicine), nurses and social workers.
The action starts identifying cases, followed by structuring a care plan, always focusing on empowering the patient and their caregivers, seeking to coordinate care between the multiple stakeholders, and creating shared information systems.
Patients can be integrated from any of the health care levels and the criteria are: adults, 4 or more visits to emergency services or 3 or more hospitalizations in 365 days, 2 or more comorbidities and polymedication (6 or more daily drugs).
Patients at the end of their lives, with mental illnesses and patients living in nursing homes were excluded.
As the project evolved, the admission criteria became more flexible, making it possible to introduce patients in earlier phases, where the benefits are more pronounced.
As soon as patients are integrated into the project, an assessment is carried out on the first home visit, defining an individual care plan taking into account the patient's expectations, definition of priorities and teaching the patient regarding self-care and identification of warning signs. Some patients are connected to the team through telehealth devices.
This program currently includes 138 patients (56% women) aged between 41 and 93 years old, with the most frequent comorbidities being heart failure, hypertension, chronic kidney disease, diabetes and chronic obstructive pulmonary disease, with an average Charlson score of 6.2 and a median of 7 on the Gijon scale.
Our results show a reduction of around 60% in emergency episodes, of 52% in hospitalizations, reduction of the average length of hospitalization from 10.5 to 8.7 days, as well as a reduction of 40% in general practitioner appointments.
With the increasing prevalence of chronic diseases being a challenge for health and social assistance, case management programs have proven to be an effective intervention measure. Our model, although limited by a small sample, demonstrated an effective reduction in the number of emergency episodes and hospitalizations, translating not only into an improvement in the quality of life but also in a potential reduction in health expenses.
This provides an opportunity to optimize patients’ self-care and promote cost-effective use of limited resources.
From a future perspective, there is the need to reorganise the resources to increase the number of patients covered, optimising care pathways, to amplify the advantages obtained so far in health and financial gains.