Implementation and Evaluation of a Novel Technology-Enabled, Integrated Case Management Program for Complex-Needs Patients in Northumberland County, New Brunswick

About the project

The New Brunswick Health Council predicts a $100 million increase in the cost of care for complex needs patients - patients who have multiple chronic conditions, often seniors - within the next 7 years. The lack of care integration and coordination among health, social, and community service providers for complex needs patients places a strain on the primary care system and impacts the quality of care. Findings from the project team’s assessment of Miramichi’s extra-mural program (EMP) services supported the development of an integrated case management (CM) approach that coordinates health, social, and community services for eligible patients. This CM approach was carried out by community paramedicine services with the aim of reducing complex needs patients’ rates of emergency room (ER) visits and hospitalizations, and improving their general health, wellbeing, and quality of life.

Conclusions and lessons learned

  • Participants experienced significantly fewer ER visits and/or hospital admissions after CM program enrolment compared to before entering the program.
  • Although clinicians were dissatisfied with the lack of processes and policies when implementing the program, they all agreed that CM is important to meet the needs of complex needs patients.
  • The case manager role streamlined communication and service delivery, providing knowledge about external resources previously unknown in their bedside clinician role.
  • Comprehensive electronic medical documentation is key for healthcare workers’ effective communication and sharing of patients’ medical information.

Recommendations

  • Develop and distribute a CM model and training program to all EMP staff before a provincial scale-up.
  • Case managers should be involved in the decision-making processes regarding CM program delivery.
  • Community paramedics should attend EMP reviews of daily caseloads prior to the planned patient visits to facilitate priority assessment and accommodation of patient needs.
  • Providing EMP patients with training to use the “Shared Care Plan” would improve continuity of care.
  • The complementary community paramedicine, CM, and EMP services should be integrated.

To learn more read the complete project findings (PDF 193 KB)

Knowledge transfer