Primary healthcare often lacks the integration and coordination of care for complex-needs patients: patients with a combination of multiple chronic conditions, who are high-cost users, and are often older. Care is benefitted from coordination among health and social services, and community organizations. A new care coordination model is needed to assist these complex-needs patients. This presentation will discuss and summarize this project, which developed a new care coordination model, with the goal to strengthen primary healthcare in the community for complex-needs patients. Using a novel, technology-enabled, integrated case-management approach, the overall goal was to decrease rates of ER visits and acute hospital admissions.

1. Implementation and Evaluation of a Novel
Technology-Enabled, Integrated Case Management
Program for Complex-Needs Patients in
Northumberland County, New Brunswick

2. 2
Funded by HSPP in October 2019, due to the pandemic, was implemented at the
Extramural Program (EMP) unit in Miramichi in June 2022;
Qualitative findings of the needs assessment and the experiences of various
participants (patients, EMP clinicians, case managers, Review Board members and
management teams)
Quantitative results in terms of patient quality of life, their satisfaction with the
community paramedicine services, including those of the clinicians and reduction of ER
visits and hospital admissions;

3. Case management approach to care
• ‘a person-centered process for quality health and social services through effective, collaborative planning and navigation of services,
resources and supports’
• Guiding the person through the service system by establishing an ongoing relationship with the individual and their family, relatives
and community to ensure access to support services.
• It supports individuals to achieve safe, realistic goals with a complex health and social environment
• Common attributes
• Single point of entry
• Uniquely targeted patients, who are most likely to benefit from the intervention,
• a comprehensive assessment of patients’ risks and needs,
• care coordination,
• individualized care planning,
• specially-trained case managers,
• multidisciplinary teams that span across sectors,
• client self-management,
• smooth transitions across care sectors
• effective health information management.
3

4. Title of this Presentation 4

5. The process
Title of this Presentation 5
Identification of the patient
Referral to the care coordination center
Assignment to case manager
Review of information by the Review Board, led by EMP in collaboration with Addictions and Mental Health,
First Nations, Social Development, Primary Care, Ability NB, ANB, community pharmacist and others, as
required to inform the care plan and facilitate case management
Development of a shared care plan

6. Profile of patients
• 98 CM patients ( 33 First Nations/65 EMP patients)
• Majority were retired, married or in a common-law relationship, lived alone and had a high school or general
equivalency diploma; rated physical health as ‘fair’; could perform most but not all activities of daily living
without assistance.
• Average time of enrollment was 3.5 months for First Nations and 5 months for the EMP group
• 13 First Nations patients were living with very mild to very severe frailty, while 8 of the EMP patients were
mild to severe frailty
• Highest patient needs were: mobility, caregiving services, mental health, equipment, diabetes management,
end of life decisions, medication management and financial.
6

7. Qualitative findings from a patient’s perspective
7
105 interviews were conducted From a Case Management
perspective:
Overall experience by the patients were
extremely positive
Individualized and continuous support
from dedicated care manager
Easy and direct communication
Invaluable support (health and social)
that positively impacted their lives and
health
From a community
paramedicine perspective:
High satisfaction from patient who
received the community paramedicine
support
•Physicial check-up, reassurance,
comfort, security and safety
surrounding health

8. Qualitative findings from clinicians and case
manager’s perspective
• From an EMP employee perspective:
• Proud to offer quality care
• Feel supported by colleagues
• Strained with workload, number of initiatives, staff shortages, paper documentation
• Don’t feel there is time with current workload to do appropriate case management; recommendation of
a dedicated case manager
• From case managers, community paramedic, members of the review board and managers:
• Agree on the importance of case management to decrease ER visits and hospitalization
• Case managers felt a sense of personal satisfaction observing the positive changes in the patient’s life
• Challenging roll out due to the pandemic
• Need to ensure clarity of role and appropriate training documentation
8

9. Quantitative Data
Patient satisfaction with Case Management
• Could candidly speak
• Phone calls were returned in a timely manner
• Treated with respect and dignity
• Considerate with their feelings
• Felt involved in their care
Patient satisfaction with community paramedic services
• Felt safe and secure
• More connected to their health needs
• Secure knowing they would be visited
• Caring and supportive
• Listening to their needs
• Improved knowledge about the services they received
• Helpful advice and information on how to maintain and improve their heatlh
9

10. Impact on ER visits and hospitalisation
• The reduction in ER visits and hospital admission for all 98 CM patients were compared between
• 1) the number of ER visits/admissions 12 months prior to the project enrollment,
• 2) the number of ER visits/admissions during the patient project enrollment, and
• 3) the number of ER visits/admissions 6 months after the patient project enrollment
• a statistically significant reduction could be observed between the number of ER visits 12 months prior and 6
month after for both subgroups.
• a statistically significant reduction in hospital admission could be observed between the number of admission
12 months prior to 6 months after enrollment.
10

11. In conclusion
• Despite the COVID-19 related challenges during the Case Management project, patients were extremely
satisfied with the services provided by the case managers and the community paramedic, and significant
reductions could be observed in terms of ER visits and/or hospital admissions.
• Frustration expressed with the lack of policies and procedures and processes, agreement that Case
Management is important in order for patients with complex needs to not fall between the cracks.
• Clinicians would love to see the role of case manager to continue, if appropriate funding and resources are
available
11