Challenges and Benefits of Developing Case Management in an ICPOP Hub

Abstract

Background: Case management is a collaborative procedure involving assessment, planning, facilitation, care coordination, evaluation, and advocacy. Its aim is to address the comprehensive health needs of individuals and families by utilising communication and existing resources to achieve high-quality and cost-effective results. The Integrated Care Program for Older Persons (ICPOP) aims to improve life for older people by providing access to tailored interventions supporting them to live well in their own homes. (ICPOP, 2017). The goal of nurse-led case management interventions within the ICPOP Hub, is to provide continuous, patient-centred, comprehensive care for older adults with complex care needs. Methods: The Nursing team, comprising Clinical Nurse Specialists, Candidate Advanced Nurse Practitioner, undertook case management of 40 patients with complex care needs, over a six-month period. Diagnoses included Delirium, Dementia, Parkinson's disease, frailty syndromes. Particular attention was given to patients who, through case management, were able to be discharged earlier from the acute hospital, aligning with the goals of the Integrated Care Model. Quality Improvement methodologies were used aiming to improve service delivery, efficiency, patient outcomes. Results: (Required) Benefits • Positive feedback from all patients and families. • Facilitating early discharge of 10 patients from hospital. • Preventing subsequent readmissions of 2 patients through proactive interventions. • Remaining patients received post diagnostic supports. Challenges • Effectively managing the expectations of families involved the care process. • Predicting exact admission avoidance due to complexities of patient medical history and the recognition that acute admissions are sometimes necessary. • Dealing with the shortage of healthcare resources at local level to provide adequate home support. Conclusion: Case management enables older adults to continue living independently at home but requires integration into a broader system prioritising seamless delivery utilising a collaborative, multidisciplinary approach to health and social care.