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Poster Abstracts

Case Managers in a Vertical Integration Health Care System : an Experience Sharing From a Regional Teaching Hospital in Taiwan

Authors:

Wei Shu ,

National Taiwan University Hospital Hsin-chu Branch, Hsin-chu, North Dist, TW
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Meng-Lan Feng,

National Taiwan University Hospital Hsin-chu Branch, Hsin-chu, North Dist, TW
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Chien-Wei Fu,

National Taiwan University Hospital Hsin-chu Branch, Hsin-chu, North Dist, TW
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Meng-Kan Chen

National Taiwan University Hospital Hsin-chu Branch, Hsin-chu, North Dist, TW
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Abstract

Introduction:

Taiwan is an Asian country with speedy aging. Healthcare demands are also changing dramatically, which make a huge grow of healthcare expenditure. Therefore, we need to re-design a more patient-centered and integrated care models to support for high quality healthcare delivery. We launched in our hospital a vertical integration health care system (VIHCS) since 2015.

The case managers are the souls of the care plans. They will provide individual and diversified care management services, so as to reduce the rates of repeated outpatient visits, emergency visits, and hospitalizations. This study aims to evaluate the efficiency of VIHCS and the role of case managers in this program.

Methods:

Our VIHCS program was carried on in a 32-bed hospitalist ward. Six dedicated attending physicians, nurse specialist practitioners, case managers, clinical pharmacists, and nursing staffs as key members in the VIHCS program. The job description of case managers are: (1) to make clarifications for the patient's multiple chronic disease histories and medication details. (2) To link the cooperation resources. (3) To discuss the aims of care and draft the discharge preparation plans. (4) To establish a multi-dimensional communication channel, contact the community hospitals and physicians at the primary care clinics which the patients are accustomed to seek medical treatment or near their homes, and hold a meeting for discussions. (5) To provide disease-related educations. (6) To perform regular monthly telephone visits, provide consulting services, and assist the patients in seeking medical treatment when necessary.

Results:

We successfully recruited 54 patients with multiple chronic diseases as the majority disease pattern. The number of emergency department visits within 6 months decreased by 75%, the rates of successful primary-care referral to the hospitals reached 19% (54/284), and the patient satisfaction rate was up to 96%.

Conclusion:

Our newly designed caring model, the VIHCS, can successfully prevent re-entry of discharge patients, reduce healthcare expenditure, and improve patient satisfaction. The case managers play an important role and function in this program.

Keywords:

case managers, hospitalist, vertical integration healthcare service, integrated care

How to Cite: Shu W, Feng M-L, Fu C-W, Chen M-K. Case Managers in a Vertical Integration Health Care System : an Experience Sharing From a Regional Teaching Hospital in Taiwan. International Journal of Integrated Care. 2021;20(S1):194. DOI: http://doi.org/10.5334/ijic.s4194
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Published on 26 Feb 2021.

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