Optimizing Patient Outcomes through Customized Phone-Based Case Management with a Holistic Approach: Re-Evaluation of a Care Coordination Model Focused on Intrathecal-Targeted Drug Delivery

Introduction: Intrathecal-targeted drug delivery is a therapeutic tool for managing intractable pain and spasticity. With this therapy, there is a need for a care coordination program to proactively and telephonically engage patients and caregivers to optimize therapeutic outcomes. Initially, the focus was on providing a one-dimensional approach to care coordination, focusing on chronic pain/spasticity issues related to patient care. However, through re-evaluation of the program and best practices in telephonic case management, gaps were identified as quality improvement opportunities. Commonly identified needs included potential emergent situations not related to chronic pain, patient crisis situations, customized telephone triage protocols designed to meet the needs of intrathecal pump patients, lack of patient resources and community support, lack of education regarding patient pain/pump therapy management, and the need for ongoing patient education and empowerment.

The program’s enhanced model aims to bridge the gap in intrathecal-targeted drug delivery therapy in order to provide patients with a comprehensive and holistic approach to maximize outcomes and provide robust value-added care.

Methods: Quality initiatives were successfully adopted. Actively participating patients with intrathecal-implanted pumps were offered an improved program model encompassing proactive telephonic nursing intervention and assessments, implementation of evidence-based clinical decision support tools customized to meet the needs of patients with intrathecal pumps, financial support services, health education, and community resources. Care coordination nurses were provided with ongoing education, training, and access to customized intrathecal telephone triage protocols in order to handle the unique disposition needs of patients treated with intrathecal-targeted drug delivery. A retrospective analysis of patients participating in the program was conducted after the implementation of the new model. Through case review, outcomes analysis, and patient engagement trends, the case management nurse team determined the unmet needs could be addressed through the incorporation of additional patient support and customized nursing interventions.

Results: Review of six months of program data demonstrates this customized phone-based care management program with a holistic approach proved beneficial. The engaged patient census grew 170%. Clinical outcomes analyses demonstrated 76% of patients had a positive perception of therapy effectiveness and quality of life. The improved care coordination model provides patients with multidimensional care to optimize outcomes.
Conclusion: The care coordination program implemented successful initiatives to collaboratively improve patient outcomes through implementation of the telephonic case management best practices and customized telephone triage protocols. The program has incorporated a comprehensive approach utilizing the biopsychosocial model. The study findings showed this new and improved model of the intrathecal care coordination program offers a more effective approach to providing holistic patient centered care; thus, improving the overall patient outcome and enhancing quality of life.