HOW IT WORKS
This pilot program is for adults with complex medical and social needs who require care from several providers. The CareNet+ network encourages strong coordination and collaboration among these providers. Enrollment is on a case-by-case basis, with eligibility determined by the case manager, a social worker who is a patient navigator/care coordinator. Various care providers, or even patients themselves, can refer to the program. The case leader is responsible for program intake as well as coordinating collaboration among providers. The case leader gathers a comprehensive history on the patient and assesses health and social care needs, based on a standardized form. Patients start working with the program within one to 60 days, depending on their willingness to cooperate and the need for urgent action. Coordination among providers is supported by the case leader through communication with team members and sharing of relevant patient information. Data exchange is oral or by e-mail, without a dedicated online data-sharing platform.
Still in its pilot phase, the program has been operating since 2016. Data are collected for operational management and external reporting. According to interim findings from external evaluators of a pilot in the Zurich region, CareNet+ patients reported improved emotional and psychological status compared to baseline and increased satisfaction in having their financial and practical needs, such as help with applying for benefits or help with transportation. Patients' self-reported health also significantly improved compared to baseline. About half also experienced a reduction in depressive symptoms and pain.
For providers. CareNet+ designates a team for every patient. The extent of the primary care provider’s involvement depends on the situation. Most often, each patient’s own general practitioner is part of the care team. Teams include health and social care providers as well as health insurance programs. They engage in cross-sector activities such as operational or management meetings, strategic planning, and rounds or patient review meetings. In this “team without walls” approach, team members are not colocated but meet regularly to discuss the patient.
For patients/caregivers. When possible, providers involve patients and caregivers in decision-making regarding care goals and individualized care plans. Shared decision-making is a central component of the program and is facilitated in most cases by a roundtable discussion; certain situations may call for a case conference chaired by a moderator. Patients are always involved in this process and must agree to the proposed measures. Empowerment and support for self-efficacy are key elements of the case management process.
A steering committee of local care providers, health insurance companies, and public authorities is responsible for strategic management and for development and implementation of the CareNet+ concept. Partners are organized into working groups.
Securing sustainable financing is a key challenge. Stakeholders recognize the difficulty of funding CareNet+ services under the current Swiss health care financing model. In the pilot, services were provided free of charge by Pro Senectute, the organization leading the project. A business model for ensuring sustainable financing is under development.
Contact: [email protected]arenetplus.ch
Additional information on impact: Evaluation report (in German), https://www.carenetplus.ch/wp-content/uploads/2018/11/Evaluationsbericht_CareNet_online_182711.pdf