Case management for patients of lower socio-economic status experiencing complex somatic and psychosocial problems (Kompass)

Why was this example implemented?

Kompass was started with the aim to facilitate access to health and social care services by providing case management for patients who are emotionally fragile, poor, socially isolated and who have  complex needs due to acute medical conditions. It addresses the gaps between acute health care and social care, as well as between hospital and home care.

Kompass aims to promote equal access to health care and social services by providing an appropriate service to the most vulnerable population groups. It also has the goal of contributing to the reduction of the average length of stay for this group of patients through  better discharge planning, one of the measures intended to prepare acute-care hospitals to “get fit for DRG’s” (Diagnosis Related Groups), that should be introduced in 2012.

Kompass supports health care providers, whether formal or informal, through case management, reducing their workload by handling complex cases professionally.

Approximatively 400,000 people live in the city of Zürich. In 2009, 17,000 people were treated in acute somatic or psychiatric hospitals. An estimated 2% of  inpatients, or 340 people annually, fulfill the admission criteria defined by Kompass.

Description

Kompass offers case management for patients with complex somatic and psychological problems.

The main partners of Kompass are the four largest public hospitals in the City of Zurich, the Stadtärztlicher Dienst, the Städtische Gesundheitsdienste and the home care services. The partners referred more than half of the patients managed by the project team. The other partners are the social services of the city of Zürich - churches, psychiatrists, general practitioners and other organisations.

At the end of the first year, the team consisted of 5 people (3.4. FTEs): 2 psychiatric nurses, 1 psychologist, 1 social worker and 1 student social worker on an internship. At the end of the year, the team had 43 open cases.

In the first year, the project team completed 111 follow-ups; approximately 30% of the supported persons were 65 or older. Thirty other cases were not admitted to the programme due to unavailability of staff. The duration of follow-ups ranges from a few days to 10 months.

What are/were the effects?

An intermediate evaluation shows that the arrangement is likely to reach the given goals. Nevertheless, the permanent implementation of the project will depend on the decision of the executive board of the health department, based on the results of the final evaluation conducted by the University of Applied Sciences of Bern.

The evaluation should show whether:

• it is possible to reconcile the social and the economic goals of the project,
• case management is an effective and economically efficient means of achieving these goals.

What are the strengths and limitations?

The big challenge of this project is the wide variety of issues team members have to handle, including medical, psychiatric and social problems as well as domestic violence, abuse, crime, or “Diogenes syndrome”. The case management approach enables efficient management  of the high average level of complexity of the cases.

The project constitutes an immediate response to a real demand of the Kompass partner organisations. Yet its permanent commissioning has to be confirmed by the City Government.

The final evaluation will establish whether the case management provided by Kompass can reinforce social equality while being cost effective.

Credits

Links to other INTERLINKS practice examples

• Coordinating Care for Older People (COPA): Team work integrating health and social care professionals in community care
• Integrated home care and discharge practice for home care clients (PALKOmodel)

External Links and References

• www.gn2025.ch/alle-projekte/kompass/beschreibung.html
• www.gn2025.ch/was-ist-das-gesundheitsnetz