HOW IT WORKS
Casaplus provides comprehensive, high-quality case management to older adults with multiple chronic conditions who are at high risk of hospital admission. Casaplus relies on case managers trained to work directly with patients. They provide direct education and coaching on self-management and lifestyle modification and, using a sophisticated data support and communication system, coordinate clients’ health and social care. The relationship between the case manager and the patient is based on mutual trust. The case manager also reaches out to informal caregivers from the outset. Other professionals, including general practitioners (GP), specialists, psychologists, pharmacists, and other care managers are also consulted if necessary.
The program was launched as a pilot in 2006 and expanded in April 2007. Both internal and external evaluations have been conducted. The program is currently being evaluated along with other European programs using standardized metrics and a common research design as part of SELFIE (Sustainable Integrated Care Models for Multi-morbidity: Delivery, Financing and Performance) a Horizon2020 EU project.
Case managers provide education and support to patients and caregivers and assume a leadership role in coordinating care with other providers. General practitioners are not necessarily involved, aside from exchanging necessary patient information with respect to medication, medical aids or nursing services.
Patients are assigned to an individual case manager, who is their main contact. The case manager works directly with the patient and caregiver.
Case managers and nursing professionals collaborate within the program. Casaplus created an online platform which supports regular communication and data-sharing among the program’s case managers and nursing professionals. Case managers receive extensive training that provides them with a comprehensive knowledge of the health and social care system, which they can draw from to suggest appropriate services to enrollees. The cost of training is completely covered by Medical Contact AG (MeCo), the founder of the programme.
The program is supported by contracts with sickness funds, which form the core of Germany’s multipayer health care system. If a person aged 55 or older is deemed at high risk of hospital admission, the cooperating sickness fund sends a personal letter to invite participation in the Casaplus program. A care manager functions as the interface between Casaplus and the sickness fund.