The more differentiated the services in a health system, the more important it is to have higher-level coordination. Care and case management concepts have existed for over 20 years to provide high-quality, needs-based health care. However, they have not yet been widely adopted into standard care. The form of care is tested and systematically evaluated in a variety of model projects. Is the time ripe for a standard benefit claim?

>> Health systems have become increasingly complex with reluctant sectors, an ever-increasing number of specialist designations and confusing service providers. The more differentiated services and the scarcer human resources are in the system, the more important it is to have higher-level coordination. Regardless of education, prior knowledge and Google, patients are regularly overwhelmed by the healthcare system. Especially for patients with complex care needs - people who are treated by more than one service provider, who are hospitalized comparatively often or who require comprehensive follow-up care after acute treatment - this represents a hurdle in asserting their right to needs-based medical treatment. The Expert Council for the Assessment of Developments in the Health Care System (SVR) has determined that, in its view, there is no justice to needs due to the lack of control of patients in the health system. Rather, there is simultaneous over-, under- and incorrect care for the affected patients (cf. SVR 2018; the term over-, under- and incorrect care was first created in the SVR report in 2001).
Structured care and case management has been discussed as a solution for many years (cf. Amelung 1999; Ewers, Schaeffer 2005). The approach is entirely analogous to the models of the community nurse in the former GDR, which contributed to ensuring patient care, especially in remote regions, since the early 1950s and became particularly well known through an evening series with Sister Agnes (Korzilius, Discounta 2006). Despite a wide variety of job titles in model projects, the term (patient) guide is increasingly becoming established. In addition to the medical services provided by doctors, they coordinate with medical and non-medical service providers as well as provide individual care for patients. d. R. over a limited period of time. The need for coordination and support arises from two considerations:
1. due to medical, therapeutic or systemic complexity
2. for particularly vulnerable patients, for example due to comorbidities, language barriers or other access difficulties.

Used in this way, guides are an essential part of the method kit for managed care. A schematic overview of the services provided by patient guides is provided in Figure 1.
There is now a lot of experience with pilots

An analysis of the projects funded in the Innovation Fund shows that 27 consortia are testing patient guides as a new form of care. The most frequently chosen indications and specialist areas are stroke, cancer, mental illnesses, geriatric care and multimorbidity.
The projects therefore particularly address diseases with complex care needs. A comprehensive overview of the pilotage projects identified, including subject area, region and brief description of the projects, sorted by start, is provided in Table 1 (see pp. 27-29).
With four projects from the first wave in the innovation fund and five projects from the second wave, many are nearing the end of their term. This creates extensive, study- and practice-based experience of what effects patient guides have in care, for which patient groups they bring advantages and how they can be connected in the most organizational sense. In addition to possible indications for which a claim to benefits in standard care must be checked, the projects also provide information on what concrete implementation could look like.
Allow diversity in pilotage concepts
Overarching, it must be stated that there is or should not be a uniform pilot concept for all support needs. Rather, the projects show that different forms of implementation are suitable if they fit the respective indication, the regional care structure or the patient group being cared for. Key findings are:
Services
• Many pilots advise on the benefits of several social codes (e.g. SGB V, SGB IX, SGB XI), which makes them more of a generalist. In some cases the advice is limited to SGB V.
• The intensity of care, even within a specialist area, varies depending on the patient. Different levels of care are therefore often set, which can be handled flexibly.
• The period of care for patients varies depending on the project between a few months to a year, sometimes even longer.
qualification
• The qualification requirements for the initial training of patient guides vary. Trained health and nursing staff and MFAs are often used, but depending on the indication, for example: B. also ecotrophologists or social workers.
• In addition to indication-specific content, further training often includes courses on communication or legal principles. The German Medical Association’s advanced training curriculum on care and case management is often followed.

Way of working
• The role of the pilots in supply varies considerably. Especially when patients are highly vulnerable, they actively support care (high contact density, checking adherence, feedback to doctors, etc.). For patients with complex care needs who only have a lack of information, they tend to provide more passive advice.
• The anchoring in the health system varies greatly. There are models in which pilots are employed on an outpatient basis by a family doctor or specialist, as well as on an inpatient basis in a hospital or in the regional care network. Freelance guides who could advise patients with the greatest possible independence would also be conceivable.

The presentation of the pilot projects also suggests the differentiation in content from existing professional groups and roles: In principle, family doctors should take on coordination functions, which is reflected not least in the family doctor-centered care introduced by the legislature for this purpose (Section 73b SGB V). However, the limited capacities of doctors prevent this model from becoming widespread. By 2035, outpatient care is expected to fall to 71 percent of its current level due to doctors retiring and too few graduates (cf. ZI 2019). In addition, from an economic perspective, it appears to be highly inefficient to entrust qualified people as doctors with a variety of non-medical tasks for organizing and administering patients. Therefore, medical representatives also support the introduction of patient guides to better coordinate care (see Ärzteblatt 2019).
In addition, social services, communication skills and competencies are primarily required to fulfill their pilotage tasks. This also applies to other non-medical health professions (such as NäPa, VerAH), which primarily provide medical support to the family doctor. For example, non-medical practice assistants (NäPa) care for patients in their own homes, but are limited to medical care and the orders of doctors, on whose behalf they undertake, among other things, injections and supportive measures for diagnostics and wound care. Patient guides, on the other hand, do not care for patients themselves - apart from regular checks on treatment adherence. However, they are not bound to the specific orders of a doctor. As a rule, this alone decides on the need for support through case management and initiates it through a regulation.

Rating positive, concrete implementation unclear
In view of the increasing number of very old, often multimorbid people with complex care needs and a fragmented care landscape, the benefit of patient guides seems obvious. The more complex the structures are for outsiders, the more support they need. In fact, the advantages of pilots from the patient's perspective are not very controversial (see IGES 2018).
• They are based on the individual needs of the patient and thus follow the model of patient-centered care.
• They combine the technical understanding of evidence-based care pathways with a social component that focuses on patient empathy and empowerment.
• They offer economic potential in the medium term, as by reducing over-, under- and incorrect supplies, e.g. B. less costly hospital admissions or even medical emergencies can be expected.

It goes without saying that patient guides are an option, but not a guarantee for patient-oriented care. It therefore often makes sense to strive for further optimization in care practice, for example to systematically collect and evaluate satisfaction and quality of life in patient reports (Patient Reported Outcome Measures, PROMs). This can also serve to identify other indications for which the use of patient lots makes sense.
The high number of health insurance companies involved in care contracts and innovation fund projects for patient guides suggests that they share a positive assessment or at least recognize potential. What seemed to prevent its introduction into standard care so far were fewer substantive concerns about the need for guidance or the expected effects on the quality of care. Rather, there were open questions about their practical integration into the existing care structures and their differentiation from the existing services of other professional groups.
There are still open questions
be clarified
Pilots are a consistent response to more patient orientation. The stronger
The more patient satisfaction is seen as an indicator of performance, the more important it is to think about the extent to which the care path makes sense from the patient's perspective. In a paternalistic health system, purely medical care would also function without a pilot. However, if patients (should) become more emancipated, then they need someone at their side for support and coordination.
It is clear that patient guides will lead to a further differentiation of professional groups in the healthcare sector. Their increase in importance in recent years is probably also related to the academicization of the nursing profession. This fundamental paradigm shift will further professionalize the management of patients and at the same time can result in a more efficient division of work between service providers. However, other questions are still unresolved:
1. Pilots are sector crossing personified. While the Social Security Code, including all regulations on planning, remuneration, quality, etc., differentiates between service providers (statutory health insurance, pension insurance, social assistance, rehabilitation and participation, etc.), people generally do not think along these lines. The complexity and coexistence of different social codes make the coordination services of pilots so important. Even with a focus on individual, complex care needs, the discussion about the financing of pilotage services is not trivial, since in addition to statutory health insurance, they can also be the responsibility of municipalities and other social service providers. The fact that the pilot projects are currently mostly financed primarily from contributions from the statutory health insurance is due more to the construct of the innovation fund or the contractual options of health insurance companies than to a systematic division of financing responsibility. Purely SGB V-related pilots would fall short of their potential and would not be able to provide patients with comprehensive support.
2. In addition, one will not be able to avoid embedding the GKV-financed services into the remuneration of the existing system. What services do pilots provide in delegation or as a substitute for a doctor? Which service components resolve an existing undersupply and are therefore extra-budgetary? In contrast, which ones just shift an existing budget between professionals? The answers to this will determine whether viable business models will emerge, independent of funding programs, that will enable patient guides to be spread into standard care. The experiences e.g. B. show with the ASV that long-term success for pilots can only be achieved with the help of such business models.

Within the Innovation Fund, patient guidance projects represent one of the largest focal points in terms of content and thus create the evidence base that is often required (see BT printed matter 19/18309). In Germany we have a tendency to carry out and evaluate countless pilot projects. In the spirit of an agile approach, it is now time to transfer the successful model projects into standard care and to quickly discuss experiences and possibilities for joint evaluation and scaling. <<

from:
Dr. Patricia Ex1, Malte Behmer1,
Prof. Dr. Volker Amelung1, 2

1 = Federal Association of Managed Care (BMC) eV; 2 = Hannover Medical School