Case management: a new tool to optimise patient health care outcomes in South Africa
In an ideal world, the right patient would receive the right care in the right place at the right time – and in the most cost-effective manner. The fragmented nature of South Africa’s health care system often means however, that this does not happen in reality. “Lack of communication between the various members of the health care team, the patient and the patient’s family is common, and not in the patient’s best interests,” says Irene Zambelis, director of the Institute of Health Risk Managers. “This is where a case manager can play a vital role.”
A case manager is someone with a clinical background, e.g. a nurse or social worker, whose primary function is to facilitate and co-ordinate the care of patients with complicated or unpredictable health conditions. “A straightforward case, like a routine appendectomy probably wouldn’t require a case manager,” continues Zambelis. “Rather we’re talking about the likes of stroke patients and those who have suffered multiple trauma, requiring the services of a multidisciplinary team. Usually the course of these patients’ recovery is likely to be unpredictable from a time, cost and health outcomes point of view.”
“During this period, the case manager will ensure the holistic care of the patient, serving as a communication link between him/her, the various treating doctors and specialists, nurses and next of kin. Because case management is primarily about communication and ensuring that all role-players are on the same page and not working in silos, it’s imperative that a case manager has excellent communication and people skills and a healthy self-image,” says Zambelis. “Liaising with all health care provider groups and co-ordinating care in the patient’s best interests requires a combination of assertiveness and diplomacy.”
Case management has been part of the South African health care landscape for the past 14 years but until early this year there was no central body representing and co-ordinating case managers. The founding of the Case Manager Association of South Africa (CMASA) in early 2009 has changed that. As a not-for-profit association, promoting professionalism, ethical values and excellence through education and training, networking and support, its aim is to promote the growth and value of case management, formulate consistent standards and support the evolving needs of the case management profession in South Africa.
“The ultimate goal is to positively impact and improve patient well-being and health care outcomes in a cost-effective manner,” says Zambelis. “As such, CMASA is dedicated to the support and development of the profession of case management through educational forums, networking opportunities and legislative involvement. “When an individual reaches the optimal level of wellness and functional capability, everyone benefits: the individuals being served, their support systems, the health care delivery systems and the various reimbursement sources. Case managers can add a huge amount of value to the health care team in helping to achieve this.”
Zambelis feels that in South Africa, there is currently a lack of common understanding between the various health care role-players on the role of a case manager. “CMASA aims to encourage the development of this, but it could take years,” she cautions. “However, the work is really beginning, and case managers have felt a huge need for a representative body that would support them, establish training requirements, set standards and terms of reference and network on their behalf.”
One of the challenges that CMASA will look to address is the paradox whereby, in a country with a critical nursing shortage, so many trained nurses have moved away from the bedside and are now working as case managers. “The vast majority of South African case managers are former nurses and we really need to get them back into the system. However, we currently have a shortfall in respect of potential case managers, given that the nurses’ clinical experience in respect of assessing appropriateness of care is essential to a case manager’s function. We still have to grapple with the details, but I believe that the solution lies in training and education.”
CMASA will also be looking to dispel myths and negative perceptions, for example that case managers’ primary function is to manage costs rather than optimise patient care. “This is not true at all,” observes Zambelis, “but that said, money is an issue and we do not have unlimited resources. Rather, the case manager’s role is to assist the health care team to deliver the best care possible with the resources available, for example by advising in respect of the benefits the patient is entitled to, appropriate ways to access these, and ensuring that they’re used to the best advantage of all.”
Case management originated in the USA as an extension of managed care/health risk management. In South Africa, most case managers still work for managed care companies, where CMASA will help facilitate their relationship with their own managers, who often don’t fully understand their role. But while CMASA will remain focused on South Africa’s unique issues and challenges, it is also tracking developments elsewhere and looking to establish international affiliates.
Zambelis foresees a time when, as in the USA, case managers will evolve into independent practitioners whom any individual or employer can hire to assess a patients’ health needs, the available funding and optimise the care they receive.
Ref no: 14/PAPA/08/09/WS
