On-Demand Learning Lab - Application of Systems Thinking in Case Management-Recording - Application of Systems Thinking in Case Management

Video Transcription

Video Summary

NACU hosted a Live Learning Lab webinar on applying systems thinking to case management, presented by Dr. Terri Stafford, a PhD-prepared nurse leader with extensive quality, certification, and Lean Six Sigma experience. She defined systems thinking as a holistic mindset for examining how interacting factors and stakeholders influence outcomes. Key steps include collaboration, understanding roles across the system, and creating processes that drive desired results. Core behaviors include holistic thinking, recognizing patterns over time, and considering all stakeholders who may positively or negatively affect outcomes.<br /><br />Dr. Stafford reviewed case management as a collaborative process of assessment, planning, coordination, advocacy, and evaluation that addresses medical needs and social determinants of health while using resources efficiently. Using three patient examples (chronic disease with low engagement, dialysis patient needing home supports and benefit education, and a complex noncompliant patient with unsafe living conditions), she illustrated how interdisciplinary local teams—RN case manager, community health worker, social worker, dietitian, pharmacist, and sometimes a nurse practitioner—coordinate across providers, community resources, and payers. Outcomes ranged from major improvement (PAM level 1 to 3; A1C 9.4 to 6.7) to limited success when patient choices and living conditions constrained care. She concluded that systems thinking requires ongoing practice: seeing the big picture, resisting quick conclusions, and identifying leverage points for change.

Keywords

systems thinking

case management

Live Learning Lab webinar

Dr. Terri Stafford

Lean Six Sigma

interdisciplinary care team

social determinants of health

patient activation measure (PAM)

chronic disease management