2026 CASE MANAGEMENT PRACTICE IMPROVEMENT AWARD
PROJECT TITLE: Every Pound Has a Story: Redefining Obesity with Empathy, Hope, and Healing
RECIPIENT: AL HADA ARMED FORCES HOSPITAL-TAIF / Sultanah Al Harbi
CATEGORY: Patient Engagement
ABSTRACT: The Case Management Practice Improvement (CMPI) Initiative was developed in response to the growing burden of obesity and the challenges associated with its identification, treatment, and long-term management. In Saudi Arabia, obesity remains one of the most prevalent chronic health conditions and is associated with significant clinical and economic consequences. Baseline assessments within Taif Region Military Hospitals revealed that although body mass index (BMI) screening was routinely performed, only 65% of patients with obesity were correctly identified and documented, resulting in delayed intervention, fragmented care, and increased reliance on costly bariatric surgery.
To address these gaps, a standardized case management-led obesity care pathway was implemented across Prince Mansour Military Hospital and Al Hada Armed Forces Hospital. Guided by value-based healthcare principles, the initiative introduced a multidisciplinary, patient-centered model focused on early diagnosis, coordinated care, patient engagement, lifestyle modification, and appropriate utilization of surgical interventions. Case managers served as patient navigators, coordinating care among physicians, dietitians, psychologists, physiotherapists, and surgeons while supporting patient adherence, education, follow-up, and shared decision-making.
The pathway was structured around the 5-D Model: Detect, Diagnose, Discuss, Decide Together, and Discharge with Follow-Up. Key interventions included standardized obesity documentation, automated BMI identification processes, dedicated case manager assignment, multidisciplinary team collaboration, expansion of lifestyle modification services, patient and family education, compliance monitoring, and continuous improvement through Plan-Do-Study-Act (PDSA) cycles.
RESULTS / OUTCOMES: The CMPI initiative demonstrated significant improvements in obesity identification, patient engagement, clinical outcomes, and healthcare resource utilization. Correct diagnosis and documentation of obesity increased by 30%, rising from 65% to 95%. Enrollment in lifestyle modification programs increased from 34% to 99%, while follow-up attendance rates improved from 52% to 98%.
Among patients enrolled in the Lifestyle Modification Clinic, the proportion of non-surgical patients achieving documented weight loss increased from 46.9% to 93.3%, demonstrating the effectiveness of coordinated multidisciplinary care and sustained patient engagement.
The initiative also resulted in a 62.8% reduction in bariatric surgeries, significantly reducing reliance on invasive interventions and supporting more appropriate utilization of healthcare resources.
Patient-reported outcomes improved substantially. Quality of life, measured through EQ-5D-5L and EQ-VAS assessments, demonstrated marked improvement following intervention, while patient satisfaction scores (PSQ-18) increased by nearly two points. The initiative also reduced avoidable emergency department visits and strengthened continuity of care through structured case management and multidisciplinary collaboration.
Beyond clinical outcomes, the initiative generated substantial economic value. When accounting for avoided surgeries, reduced emergency department utilization, and quality-adjusted life year (QALY) gains, the total estimated cost savings ranged from SAR 11.5 million to SAR 13.7 million (USD 3.07–3.65 million).
This project demonstrates how a case management-led, value-based obesity care pathway can improve clinical outcomes, enhance patient engagement and adherence, optimize healthcare resources, reduce unnecessary surgical interventions, and generate measurable economic impact. The initiative highlights the transformative role of case management in advancing patient-centered obesity care and provides a scalable model for chronic disease management across healthcare systems.
BENCHMARK: Baseline performance demonstrated that only 65% of patients with obesity were correctly identified and documented despite routine BMI screening. Following implementation, obesity identification and documentation increased to 95%, exceeding the project target of 85%. Significant improvements were also achieved in lifestyle program enrollment, follow-up compliance, patient-reported outcomes, and reduction of bariatric surgery utilization.
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