The added value of a mobile application of Community Case Management on referral, re-consultation and hospitalization rates of children aged under 5 years in two districts in Northern Malawi: study protocol for a pragmatic, stepped-wedge cluster-randomized controlled trial.

BACKGROUND: There is evidence to suggest that frontline community health workers in Malawi are under-referring children to higher-level facilities. Integrating a digitized version of paper-based methods of Community Case Management (CCM) could strengthen delivery, increasing urgent referral rates and preventing unnecessary re-consultations and hospital admissions. This trial aims to evaluate the added value of the Supporting LIFE electronic Community Case Management Application (SL eCCM App) compared to paper-based CCM on urgent referral, re-consultation and hospitalization rates, in two districts in Northern Malawi. METHODS/DESIGN: This is a pragmatic, stepped-wedge cluster-randomized trial assessing the added value of the SL eCCM App on urgent referral, re-consultation and hospitalization rates of children aged 2 months and older to up to 5 years, within 7 days of the index visit. One hundred and two health surveillance assistants (HSAs) were stratified into six clusters based on geographical location, and clusters randomized to the timing of crossover to the intervention using simple, computer-generated randomization. Training workshops were conducted prior to the control (paper-CCM) and intervention (paper-CCM + SL eCCM App) in assigned clusters. Neither participants nor study personnel were blinded to allocation. Outcome measures were determined by abstraction of clinical data from patient records 2 weeks after recruitment. A nested qualitative study explored perceptions of adherence to urgent referral recommendations and a cost evaluation determined the financial and time-related costs to caregivers of subsequent health care utilization. The trial was conducted between July 2016 and February 2017. DISCUSSION: This is the first large-scale trial evaluating the value of adding a mobile application of CCM to the assessment of children aged under 5 years. The trial will generate evidence on the potential use of mobile health for CCM in Malawi, and more widely in other low- and middle-income countries. TRIAL REGISTRATION: ClinicalTrials.gov, ID: NCT02763345 . Registered on 3 May 2016.

Towards personalized integrated dementia care: a qualitative study into the implementation of different models of case management.

BACKGROUND: The aim of this process evaluation was to provide insight into facilitators and barriers to the delivery of community-based personalized dementia care of two different case management models, i.e. the linkage model and the combined intensive case management/joint agency model. These two emerging dementia care models differ considerably in the way they are organized and implemented. Insight into facilitators and barriers in the implementation of different models is needed to create future guidelines for successful implementation of case management in other regions. METHODS: A qualitative case study design was used; semi-structured interviews were conducted with 22 stakeholders on the execution and continuation phases of the implementation process. The stakeholders represented a broad range of perspectives (i.e. project leaders, case managers, health insurers, municipalities). RESULTS: The independence of the case management organization in the intensive model facilitated the implementation, whereas the presence of multiple competing case management providers in the linkage model impeded the implementation. Most impeding factors were found in the linkage model and were related to the organizational structure of the dementia care network and how partners collaborate with each other in this network. CONCLUSIONS: The results of this process evaluation show that the intensive case management model is easier to implement as case managers in this model tend to be more able to provide quality of care, are less impeded by competitiveness of other care organizations and are more closely connected to the expert team than case managers in the linkage model.

Use of standardized multidimensional evaluation tools and the emergence of the case manager's professional identity in France.

In France, the national public health plan proposes a group of innovations including the initiation of case management for older adults in complex situations, particularly those with cognitive disorders. In this context, public authorities asked case managers to use a standardized multidimensional evaluation tool. The results of a qualitative study on the pertinence of such a tool relative to the emergence of this new professional field are described. Early use of an evaluation tool seems to be linked to the emergence of a new professional identity for recently recruited case managers. Factors determining the strength of this link are training tool standardization, computerization, and local structure's involvement. Our results contribute to identifying one of the ways by which professional identity can be changed to become a case manager.

Interventions to address violence associated with mental illness.

OBJECTIVES: The aim of this paper is to consider the association between mental illness and violence, and discuss broad intervention approaches. CONCLUSION: The necessary elements of intervention to reduce violence by the mentally ill are holistic care, access to services and, where necessary, legal leverage. In the custodial setting, this includes screening, early intervention and treatment in prison, and assertive post-release case management to divert mentally ill offenders away from substance use and to support their return to the community. In the community setting, active case management, including access to inpatient beds and co-ordination between mental health services and other agencies, is crucial to providing continuity of care for patients at risk of violence in the community.

The evolving role of care management in integrated models of care.

The purpose of this study is to better understand care management in integrated models of service delivery. Semistructured interviews were conducted with state- and program-level administrators and care managers from nursing and social work disciplines in eight programs providing integrated care. The professionals interviewed discussed the benefits and difficulties associated with providing care management to a population with a wide range of needs, issues related to interfacing with different health care professionals, and the overall purpose of the care manager role. The findings suggest a need to unify the purpose of care management in programs, that educational and training efforts for care managers need to be examined more closely, and that there is a need for future research to focus on the value of comprehensive care management in a medical model of care.

Molecularly targeted therapy in renal cell carcinoma: where do we go from here?

The angiogenic phenotype of renal cell carcinoma results from vascular endothelial growth factor pathway activation. Several different strategies targeting various aspects of the pathway have emerged as clinically relevant therapeutics in metastatic renal cell carcinoma. Key clinical data regarding these approaches are presented in this article. Furthermore, there are several considerations as to the further development of these agents and their appropriate application in metastatic renal cell carcinoma, such as timing of therapy, choice of initial therapy, continued role of debulking nephrectomy and toxicity concerns. These issues are discussed in light of current data and strategies for further drug development are presented.

Thalassemia: the continued challenge.

This overview describes the history of transfusion therapy and consequent iron overload in thalassemia. It emphasizes the importance of measurement of hepatic iron and reviews the history of chelation therapy. It briefly describes the discoveries of the genetic basis of thalassemia and the application of that knowledge in prenatal diagnosis. The review goes on to emphasize pharmaceutical efforts to induce fetal hemoglobin synthesis in thalassemic red cells and ends with a discussion of oral iron chelators, stem cell transplant, and the status of gene therapy.

Build a bigger hat rack: case managers' duties expand to outpatient care.

With the current national trend toward fully integrated health care systems, hospital-based case managers are becoming crucial to the expansion of acute care facilities into the outpatient arena. While many may still be getting used to juggling both clinical and financial duties, others--particularly at small, rural hospitals--are taking on even more responsibilities. While there are advantages to having inpatient case managers oversee outpatient and community care--including shortening inpatient length of stay in some cases--most inpatient/outpatient models have drawbacks as well. In particular, case managers are required to maintain a flexible outlook that encompasses the entire continuum, rather than just one slice of it. One potential result of the trend toward outpatient case management could be an increased willingness on the part of managed care organizations to subcontract work with hospital-based case management departments to handle outpatient programs.

The impact of mental health service integration on systemic function: a staff perspective.

OBJECTIVE: The purpose of this study was to investigate the perceptions of community staff regarding service process and quality, while a public mental health service integrated acute inpatient and continuing care components. METHODS: The study employed a naturalistic successive measures design in which community mental health staff completed a questionnaire on three occasions during the integration process. RESULTS: Staff perceived overall service quality to improve during the integration process with continuity of care being the area subject to greatest improvement. CONCLUSIONS: The integration of acute inpatient and continuing care services resulted in changes to service process and outcome, which were judged by staff to be beneficial, especially with respect to continuity of patient care.

Redefining the role of clinical nurse specialists.

Leadership in a time of change requires personal and professional skills. As nursing responds to the evolving health care environment, the advanced skills of the clinical nurse specialist (CNS) are needed to promote a relationship with the client that is holistic and fiscally responsible. Positioned within vertically integrated corporations as community case manager, the CNS has an opportunity to bring innovative interpretations to the roles of practitioner, consultant, educator, and researcher.