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.
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