Several project directors mentioned that the linkage coordinators took time to orient ARTAS clients to the case management system and the services that their case manager could provide.
Such ACP models should aim to overcome barriers and facilitate ACP at the case manager, client and caregiver and system levels.
During the treatment phase, the case manager coordinated the cancer care system, arranged appointments between disciplines, monitored treatment effects and possible complications, provided education and training about disease care and management of side effects, offered emotional support, and improved the adherence for treatment completeness.
We categorized these interventions into four themes: (1) retention in care promoting activities by the health facility, (2) retention in care promoting activities by the community-based organizations, (3) the coordination of the retention in care promoting activities by the case manager(s), and (4) patient information systems managed by the data clerks(s).
The framework has got four pillars: activities by the health facility, activities by the community-based organizations, coordination of these activities by the case manager(s), and patient information systems by the data clerk(s).
Farber at al. [ 4], in their review of the literature, found that numerous terms were used to describe the role of various kinds of navigators in the health care system, such as case manager, clinical coordinator, support nurse, etc.
The role of social workers is often that of case manager, in that they integrate formal systems of care into the activities of families and other primary and community groups (Moore 1990).
We identified four themes that contributed to better and improved retention in care in high performers: (1) retention in care promoting activities by health facilities, (2) retention in care promoting activities by community-based organizations, (3) coordination of these activities by case manager(s), and (4) patient information systems by data clerk(s).
Health facilities with higher and improving patient retention were found to implement a comprehensive package of interventions: (1) retention promoting activities by health facilities, (2) retention promoting activities by community-based organizations, (3) coordination of these activities by case manager(s), and (4) patient information systems by data clerk(s).
After an initial assessment of needs, the case manager and service user collaborate on a system of referrals, monitoring, follow-up assessment and advocacy to ensure positive outcomes.
