CASEPLUS-SimPat: An Intersectoral Web-Based Case Management System for Multimorbid Dementia Patients.

One main challenge of health care systems in future will be the care and treatment of dementia patients. To their advanced age, dementia patients do not only have limitations in cognition, perception, and articulation, but also suffer from several other diseases (multimorbidity). These patients have sophisticated needs for assistance, care, and treatment relying on different health care sectors. Well-known communication and coordination deficits between sectors are intensified in the case of dementia, to the above described limitations. Coordination processes concerning the transition of patients from hospitals to inpatient or outpatient aftercare pose particularly difficult. To show a possible future direction for improving intersectoral care of dementia patients, we developed the web-based case management system CASEPLUS-SimPat as part of the project SimPat "Securing Integrated Care for Multi-morbid Patients with Dementia using an IT-based Service Concept". CASEPLUS-SimPat allows health care professionals, hospital employees and general practitioners, to jointly access patient data and exchange information about the treatment of patients. The case management system was implemented in a three-tier architecture with a role-based authorization concept. A portal for relatives complements the system. By providing precise information and e-learning services, caring relatives are integrated into the care process. In a pilot test, CASEPLUS-SimPat shows a good usability. Adapting aspects, such as keywords used to structure entries will make it easier to find required information, and thus will increase usability. Next steps comprise integration of further health care professionals and care facilities as well as real-life testing in terms of feasibility and effectiveness.

Information and Communication Gaps in Intersectoral Healthcare Processes for Dementia Patients.

In addition to general barriers of information exchange and communication in intersectoral healthcare processes, the healthcare process of dementia patients has unique requirements regarding the communication and information exchange of the various healthcare professionals and non-professional caregivers, such as relatives or their legal caregivers. We conduct a process analysis to determine the status quo of such healthcare processes in the region of Darmstadt, Germany and elicit existing gaps in the information and communication exchange. We identify key processes by performing a document analysis and conducting interviews with seven different healthcare professionals. The results of a weak point analysis based on advanced event driven process chains (EPC) point out 32 information and communication gaps summarized in four categories: "information exchange", "information transfer" "information provision" and "activity impulse". Our results show further opportunities regarding the support of caring relatives and primary care physicians.