Case Management of Long-term Conditions

JANET SNODDON is Deputy Director of Corporate Performance & Standards, NHS Sefton She was the Lead for Long Term conditions at both South Sefton and Southport and Formby PCTs (organisations which have now merged into NHS Sefton), developing case management services. She is also the Non Medical Prescribing clinical lead for Northwest SHA.

Introductionix

1 Background to the Implementation of Case Management Models for Chronic Long-Term Conditions within the National Health Service 1

Introduction 1

Primary care management of long-term conditions 2

How management approaches have been developed 3

Developing and delivering care 4

Future of care 5

The impact and cost of chronic disease 6

Identifying patients who require case management 7

National guidelines and evidence-based practice 8

Embedding evidence in practice 8

Making progress in the management of chronic conditions 9

Modernising care in the National Health Service 10

Developing case management and care delivery 10

Case management in the National Health Service 11

Promotion of self-management and self-care 13

Partnerships and expectations 13

Conclusion 15

References 15

2 Case Management Models: Nationally and Internationally 18

Introduction 18

The context for case management in the NHS 20

Impact of managed care models 21

International models of care reviewed 22

The Alaskan Medical Service 22

Kaiser Permanente (North California) 24

Group Health Cooperative (Seattle, Washington) 25

HealthPartners (Minnesota) 25

Touchpoint Health Plan (Wisconsin) 26

Anthem Blue Cross and Blue Shield (Connecticut) 26

UnitedHealth Europe Evercare 26

Amsterdam HealthCare System (the Netherlands) 27

Outcome intervention model (New Zealand) 28

National model of chronic disease prevention and control (Australia) 28

Guided Care (United States) 28

PACE (United States) 28

Veterans Affairs (Unites States) 29

Improving Chronic Illness Care (Seattle) 29

Expanded Chronic Care Model (Canada) 29

Pfizer (United States) 29

Green Ribbon Health: Medicare in health support (Florida) 30

What do these models provide? 30

Models in use in England 30

Care management in social care 32

Case management models in the NHS 32

Joint NHS and social care 36

Data for case management 38

Evaluation 38

Conclusion 40

References 41

3 Competencies for Managing Long-Term Conditions 43

Introduction 43

Development of the competency framework 44

What the competencies are expected to deliver 46

The competencies: what are they? 46

Domain A: advanced clinical nursing practice 47

Domain B: leading complex care co-ordination 49

Domain C: proactively manage complex long-term conditions 52

Domain D: managing cognitive impairment and mental well-being 52

Domain E: supporting self-care, self-management and enabling independence 55

Domain F: professional practice and leadership 57

Domain G: identifying high-risk people, promoting health and preventing ill health 58

Domain H: end-of-life care 59

Domain I: interagency and partnership working 60

What the competencies aim to do 61

Developing educational models to develop competencies 62

Conclusion 64

References 64

4 Outcomes for Patients – Managing Complex Care 66

Introduction 66

The areas of competence and deliverables for patients: Leading complex care co-ordination 66

Identifying high-risk patients, promoting health and preventing ill health 74

Interagency and partnership working 77

Conclusion 82

References 82

5 Outcomes for Patients – Advanced Nursing Practice 85

Introduction 85

Advanced clinical nursing practice 85

Proactively manage complex long-term conditions 91

Professional practice and leadership 94

Managing care at the end of life 97

Conclusion 101

References 102

6 Outcomes of Case Management for Social Care and Older People 105

Introduction 105

Policy drivers for the care of older people 105

Health and social care integration 108

Cost of care for older people 109

What do people expect in old age and how will these services be commissioned? 111

What does case management offer to older people? 112

Integrated models of care 114

Impact of case management on older people 114

Managing resources 118

Outcomes for older people 118

Conclusions 119

References 120

7 Outcomes for Patients – Cancer Care and End-of-Life Care 123

Introduction 123

Gold Standards Framework for Palliative Care 125

Integrated Cancer Care Programme 125

Preparing for the pilot programmes 127

Delivering the pilots 129

Programme outcomes 130

Case Management and ICCP 131

Case management competencies – what can/should patients expect? 132

The real need for competencies 137

Advanced care planning 139

Preferred place of care and delivering choice programmes 140

Conclusion 140

References 142

8 Leadership and Advancing Practice 144

Introduction 144

What is leadership? 144

What does leadership provide? 145

Leadership framework in the NHS 146

Skills in leadership 147

Political understanding and functioning 148

Setting targets and delivering outcomes 148

Empowerment and influencing 149

Levels of competence 150

Other leadership frameworks 150

What does good leadership do? 153

Impact on organisations 153

Leadership in case management 154

Leadership and change 155

Leadership is in every role 156

Advanced practice 157

Prescribing 158

Advanced practice in long-term conditions 159

Conclusions 160

References 161

9 Self-Care and Patient Outcomes 164

Introduction 164

What is self-care? 164

Self-care and practitioners 167

Systems for self-care 168

Expert Patient Programme 168

Effectiveness of self-care programmes 169

Promoting self-care: staff role 170

Self-care: models 171

Self-care: the evidence base 173

Using information and technology for self-care 175

How do we engage patients in self-care? 179

Conclusions 180

References 183

10 What Does This Mean for Patients? 185

Introduction 185

Government expectations 186

What do patients want from care? 186

Reported outcomes from management of long-term conditions 187

Modernisation to enable outcomes for users of services 188

Do patients really see improvement? 188

Understanding the patient experience, how we find out? 190

Public Service Agreement targets 192

Other assessments of user/patient experiences 192

Patient-centred care 195

Allowing patients to tell their tale 195

Outcomes of care and patient experience 195

Experience in case management 197

Partnerships with patients: impact on experience 199

Quality for patients 200

Impact of the provision of information on patients’ views and outcomes 201

Conclusions 201

References 203

Index 207