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:
 Extremely complex care
 Wide variety of interdisciplinary teamwork
 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”
 A study performed in 2012 revealed that about 31.1% of
diagnosed HNC patients experienced delays in care or were
lost among the system (Price & Murphy, 2014).
 Current State

 Psych:
 Case management is mainly in the hands of social
workers or psychiatrists (Arkansas Psychological
Association, 2017).
 Cancer:
 Vast interdisciplinary team involved
 Coordinators for Hepatic, lung, and hemoncology
 SAVAHCS have cancer committee headed by Dr.
Mgegawa
 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.
Possible Solutions (Future State)

 Common template for facilities/units to utilize in order for the whole health team to be on
the same page and make information easily accessible.
 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.
 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,
2010).
Nurses’ Role in Case Management

 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, 2010)
 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. For follow-up treatment, including the family decreases the likelihood of relapse (Kassani,
Niazi, Hassanzadeh, & Mendati, 2015).
2. 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)
Insights from Literature Review cont.

1. Standards of Practice from the Case Management Society of America (2010) aims to
minimize fragmentation in the health care system by expanding interdisciplinary team and
improving patient safety.
2. Nursing case management decrease readmission rates and increases continuity of care
and improves the effectiveness of overall treatment (Chen, Chang, Tsou, Chen, & Pai,
2013).
3. Price and Murphy (2014) presented at the Association of VA Hematology/Oncology
conference regarding cancer tracking system for ear, nose, and throat cancers. They
found that an automated tracking tool provides for optimal treatment interventions and
prevents patients from slipping through the cracks thereby enhancing patient centered
care. They also found the benefits of electronic tracking system include optimized time,
work flow, and enhanced patient safety.
 Potential Impact

 Improved patient outcomes

 Increased preventative measures implemented
 Improved patient satisfaction
 Increased patient safety
Recommendations for future
review/action

 Implement template in other units/clinics

 Make electronic template more accessible
 An experiment can be performed; 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.
 Implement automated tracking tool since manual tracking tool is labor intensive and may
miss important patient information.
 Utilize this tool as part of the VA’s requirements to obtain annual accreditation through the
American College of Surgeons. To assure that the hospital is upholding the standards of care for
cancer patients.
Question? Comments?
References

Case Management Society of America (2010). Standards of practice for case management. Little
Rock, Arkansas.
Chen, Y. C., Chang, Y. J., Tsou, Y. C., Chen, M. C., & Pai, Y. C. (2013). Effectiveness of nurse case
management with usual care in cancer patients at a single medical center in Taiwan: A quasi-
experimental study. BMC Health Services Research, 13, 202.
http://www.biomedcentral.com/1472-6963/13/202
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
Price, F. B. & Murphy, R. G. (2014). Systems automation for cancer surveillance: A useful tool for
tracking the care of head and neck cancer patients in the ear, nose, and throat clinic,
Association of VA Hematology/Oncology, New Mexico, September 4, 2014.