ADAPTIVE CASE MANAGEMENT; WHAT DOES THAT MEAN TO THE PATIENT?

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Case management is a poorly understood term.  We are case managers and have looked for another word for years to describe what we do but can’t find one.

According to the formal definition: case management is a collaborative process of assessment, planning, facilitation, care coordination, evaluation, and advocacy for options and services to meet an individual’s and family’s comprehensive health needs through communication and available resources to promote quality costeffective outcomes.

Case management has evolved from social work and from the insurance industry. It has been used in healthcare for years but the term is now being applied in a new context in healthcare to describe the information systems and processes used to manage complex cases.

Healthcare is the single largest business segment in the world. It accounts for about 10% of global GDP (OECD 2009). Information technology in healthcare has lagged behind other industries such as banking and aviation. Massive efforts are being made to buy solutions. However, the solutions are usually institution-centric and not patient centric. This creates a silo of stand alone systems that don’t integrate.

Furthermore, electronic health record systems are designed for processes that are repetitive and routine.  When knowledge workers use electronic health records to do work that is not repetitive and not routine and is uncertain and unpredictable, then there are limitations to the use of these tools. These systems are not designed for this type of knowledge work. That is why adaptive case management is getting more air time now.

Adaptive case management (ACM) is being used to describe the work processes and information systems that specialized healthcare knowledge workers or experts use with structured and unstructured information and unpredictable work flows and processes. Routine work is predictable. Knowledge work is unpredictable. Knowledge workers engage in unstructured and collaborative processes which are complex negotiations. The collaboration between care providers has high transaction costs because the IT connections between care providers are not highly efficient.

ACM moves the process knowledge gathering in the life cycle of the case from the template analysis/modeling/simulation phase into the process execution. The ACM system collects actionable knowledge based on process patterns created by business users.  The knowledge workers are driving the bus with ACM.

Adaptive case management (ACM) brings together process, content and customer relationship management. It plays a key role in execution toward stated healthcare goals.  The outcomes are based on intelligent adaptation and work arounds to the specific situation as it unfolds. The adaptation is based in “local rationality” and “context”.

Max. J. Pucher is an expert in ACM. Mr Pucher stresses the importance of goals.  He states that the needs of healthcare knowledge workers who perform emergent or unstructured knowledge work are very different from repeatable production work.  The processes in ACM can not be mapped and rigidly managed. If the process is defined too exactly, then the process becomes fragile and breaks upon encountering the first exceptional situation.

ACM when used for healthcare cases must have multiple pathways and must cope with diversity or it will fail. Workflows are driven by decision making and content status. ACM for healthcare must exhibit adaptive, dynamic, goal seeking, collaborative decision making and must have self-preserving, self-correcting and evolutionary behaviour. ACM is driven by the knowledge workers based on their step by step decisions.  The key is to put the right resources in the hands of the workers so they can make the right decisions at the right time.

When analyzing this work, traditional process mapping and management approaches do not work. Unexpected outcomes may commonly arise. The role of the care provider in this uncertain environment is similar to a “choreographer” of underlying clinical services, coordinating assessment and treatment delivered through a range of providers and organizations and across a range of care facilities.

The essential building blocks required to deliver integrated care which is the secret sauce are: integrated patient data, decision support information and expert advice through collaboration to enhance decision making. The ACM process is data-centric unlike business process management (BPM) which is process centric.

ACM also tries to improve the performance of an organization, but instead of considering the process primary, it is the case information that is primary. This information is an information resource, which will be accessed over the length of use, and in many situations will become the official record for that work. There can be processes, but the processes are brought to the case, and run in the context of the case, rather than the other way around.

Because of the need to access experts for their specialized knowledge, a best practices framework is often applied in healthcare. This is a generic outline and starting point for the process. But the best practices framework will likely be modified over time based on new learnings, new knowledge and new decisions in order to adapt to the complexity of the case.

The first objective in managing the ACM process is to select the process owner. He/she will tailor the general framework based on the details of the case, articulate the goals and start the steps of the process. Every process has a goal, deadline and defined work product (outcome).  Regular collaboration must be part of the process in order to access specialized knowledge.

Expert processes are emergent and visibility and control are only achieved in the context of execution of a process instance or after it is complete. Visibility is achieved by monitoring the process and enabling the process owner to view the whole process ( both past and present). Monitoring provides details on both the emerging flow of the process and work done by each participant. Control is achieved by tracking deadlines and goals.

According to Max J. Pucher, ACM cases are usually not designed up-front. That is the adaptive nature. They are derived from well defined goals, case templates, targeted customer outcomes, tasks and operational targets that link to process goals. So the work is goal-oriented and tasks are assigned to work towards goals. Such task lists can later be reused to create a mind-map (process) for achieving the same goal again, but it is not a hard-coded flow. Workers can still modify the goal-template until the customer reports a satisfactory outcome. Constraint rules are used to ensure compliance to internal and external regulation. If such case templates are better or worse is judged by the process owners based on achievement of the goals, objectives and outcomes.