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Care management in the home visit - a model project
Care management in the home visit - a model project

Since August 2022, our supply network has been using a so-called outreach care management established for people with ALS. In the model project, patients who require complex care but receive little support are cared for by an experienced assistive technology coordinator from our case management team visits you at home.. In the home visit, the care situation is to be recorded more precisely and improved individually. We offer outreach care management in the states of Berlin, Brandenburg, Mecklenburg-Western Pomerania, Saxony-Anhalt, Saxony and Thuringia an. We were able to win Mr. Daniel Kufeld as assistive device coordinator for the model project. Mr. Kufeld has many years of experience with complex assistive devices and is familiar with the care of people with severe neurological diseases.

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Figure: In outreach care management, Daniel Kufeld ensures that patients receive appropriate care and is the point of contact for care during the course of their illness.

The motivation

In practice, the increasingly complex care needs resulting from the progressive motor impairments in ALS are encountering more and more differentiated care services. In addition, there is a wide range of counseling services for specific symptoms of the disease - all of which is becoming increasingly difficult for those affected to keep track of.

On the other hand, this also applies to the treating physicians: Our scientific publication of data on the provision of medical aids in ALS in 2015 shows that in over 35% of documented care processes inadequate supply of assistive devices by the individual players was available (Fachzeitschrift Nervenarzt August 2015)

The primary purpose of our outreach care management program is to ensure that patients who are iReceive relevant information appropriate to your situation and support them in organizing appropriate care. In this context, care management is a independent representative of patients' interests vis-à-vis health insurance companies and medical supply stores. For this purpose, Daniel Kufeld is available after a home visit as a continuous contact person for consulting and problem solving.

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Figure: Outreach care management supported by care algorithm. The algorithm generates care recommendations and records deficits in care. Based on the data, a decision is made to visit the home of the person concerned. Outreach care management in practice

For the model project, we developed a care algorithm for people with ALS. The care algorithm provides on the one hand Supply recommendations for the compensation of motor impairments with assistive devices and records on the other hand Deficits in the supply of aids. The recommendations are generated by digital analysis of patterns in the ALS Functional Rating Scale Revised (ALSFRS-R), which is collected by patients themselves - in the sense of a "self-assessment". Care deficits are identified by analyzing care processes in our network.

The algorithm-based care recommendations and the identification of care deficits serve as a Support for the decision on the need for a visit in the home. After discussing the care recommendations and care deficits in our case management, a decision is made about a home visit.

With the data-based decision on a visit to the home, the affected persons - if they agree - are visited and advised by Daniel Kufeld. As part of quality management, Mr. Kufeld records the individual care situation. In the next step, our case management checks the need for care and communicates it to the attending physicians. The decision to supply an assistive device is then made by the physician. The responsibility for the The indication for care therefore remains with the physician..

The impact of outreach care management on quality of care will be investigated through a scientific analysis of data from care processes. Our hypothesis is that home visits will improve the care of people with ALS.

We thank you for your interest in the model project. If you have any questions, please do not hesitate to contact us.

Your APST team

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Barbara Hildebrandt
Supply Management
Tel. 030-81031410