by Siyabonga Gema, HST Communications Officer and Judith King, HSS Copy and Content Editor
Department of Health and HST staff working on case management at Eastwood Clinic in Pietermaritzburg.
Batho Pele / People First – which was conceived with the intention of transforming service delivery in the public sector – is founded on the principle that good service delivery leads to happy customers and employee satisfaction.
This is especially true in the health facilities based in uMgungundlovu District that have implemented Health Systems Trust's Case Management Model II (CMM2) ‒ a patient-centred model that assigns individual patients with chronic medical conditions to a single Clinician supported by members of the multi-functional facility team.
The mission of case management
Case management is a practice focused on delivering personalised, holistic and high-quality health care, so as to achieve the desired health outcomes, reduce patients' unmet needs, enhance a positive experience of health care, and foster involvement of patients in their health care. The CMM2 also motivates and inspires healthcare providers and contributes to sustainable health service delivery systems.
Benefits of case management
This modality ensures that patients feel well-supported.
- It promotes a positive patient‒clinician relationship based on efficient and responsive service delivery, thereby creating mutual trust.
- Healthcare workers are confident and fulfilled in their work environment.
- Healthcare providers are empowered with leadership and data management and analysis skills.
- Overcrowding, long queues and long waiting times are radically reduced.
Case management has particular benefits for continuity of care among patients on antiretroviral therapy (ART), through close viral load management to the point of suppression and transitioning patients to differentiated models of care (DMoC) once they are clinically stable. Applying this modality also ensures that patients in DMoC remain supported, so that they have unbroken access to medication and guidance to avoid treatment interruption.
The model strengthens linkage to care through tracing, tracking and close follow-up of patients, helps to sustain them through their treatment journey through adherence counselling, appointment reminders, and referrals when necessary for other supportive services.
CMM2 implementation also facilitates care continuity for hospitalised patients, and improved tracing and testing of contacts of patients admitted with tuberculosis (TB).
CMM2 implementation in facilities
Patients in the Chronic Stream (whether they are living with HIV, TB, and/or a non-communicable disease) follow a colour-coded signage route to their Case Manager and related care-provision team.. The Clinicians are trained to analyse their own data, and to present on the CMM2 Dashboard content for discussion. Each team leader is concerned about poor results and strives to excel, with a clear goal of progressing their patients to stable viral suppression and transition to DMoC. They present data at weekly Nerve Centre meetings, and all staff understand what the data mean; everyone works together on quality improvement strategies. The real-time data updates and clean-up ensure that no gap is missed. This leads to strong accountability for individual and team performance, and growth of broader skills, so that the model constitutes an instrument for contextual understanding of a facility's service profile and its catchment area.
This is a joint venture, where HST provides technical support and monitoring, and the Department of Health is the driver of the system in facilities.
Visiting two CMM2-implementing facilities in uMgungundlovu
On 5 and 6 October 2023, the uMgungundlovu SA SURE PRO project team was joined by members of HST's communications and training units in visiting two of the implementing facilities: Eastwood Clinic in Pietermaritzburg and Richmond Clinic in Richmond. The group aimed to benchmark and package good practice in CMM2 implementation for replication in other facilities.
A briefing in Richmond Clinic's Chronic Stream
Clinicians from Eastwood and Richmond Clinics took the delegation through the process flow, and the various stages followed by each case-managed patient. The group observed the progress made, and brainstormed strategies for communicating and promoting the impressive work being carried out by the dedicated health professionals involved in the roll-out of the model.
Sr Nhlebela, Operational Manager for Richmond Clinic, gave the background of case management implementation in the facility. "Case Management was first introduced in October 2022. At first, there was some reluctance among staff, but this was quickly overcome after the HST implementing team explained the benefits of the system and the facility decided to adopt it.''
Eastwood Clinic was the first in the district to implement the CMM2 protocols for file flow. Pre-retrieval of patient files and staff being responsible for movement of the files from point to point during the patient's visit have ensured file security, and shortened waiting times through increased efficiency.
During the visit to Eastwood Clinic, the Communications Unit engaged with Clinicians and patients to get a sense of how case management has improved service delivery and experience of care, respectively.
One of the patients who has received care at Eastwood Clinic since 2010, says that service delivery has improved drastically, pointing out that she spends less time in the facility due to the smooth process flow. Patient waiting times have been shortened from five to three hours (from arrival to departure). Another point that emerged from the interviews was that patients are happy to have one clinician who sees them at every visit, and with whom they have developed a relationship. An improved patient satisfaction score had been demonstrated through an externally conducted survey.
District DoH endorsement and support
The Medical Manager of Richmond Hospital, Dr Bulelane Gebashe, who had joined the visit to Richmond Clinic, observed that the CMM2 has changed ways of working to significantly ease the burden on staff and patients, and that the positive performance results for all indicators – including data management – can be attributed to CMM2 implementation. "It is clear to see how fulfilled and motivated the staff members are," he said. As he was in charge of monitoring patients' complaints and compliments, he emphasised how important the shorter waiting time is for patients – sharing that his own home helper "raves about Richmond Clinic".
The Operational Manager of the Clinic, Sr Nhlebela, reported that many patients call their Clinician "mother", and feel supported in their knowledge of the clinic process, referring to "my green chair", for example.
Dr Gebashe noted that the CMM2 has led to integration for a fully functional facility. The team structure shows how important each member is, and the model instils an ethos in which every person, whether a provider or a patient, is valued, which in turn makes the community feel valued, as expressed by the clinic committee members.
Clients from other areas (such as Ndaleni, which is 30 minutes' drive away) are coming to Richmond Clinic because of its reputation. This is a considerable achievement for a clinic that serves approximately 8 000 people per month, and he thanked HST for leading the facility to innovation.
"Hope is that thing inside us that insists ‒ despite all evidence to the contrary ‒ that something better awaits us if we have the courage to reach for it, work for it, and fight for it."
Former US President, Barack Obama
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