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.

• Introductionix1 Background to the Implementation of Case Management Models for Chronic Long-Term Conditions within the National Health Service 1Introduction 1Primary care management of long-term conditions 2How management approaches have been developed 3Developing and delivering care 4Future of care 5The impact and cost of chronic disease 6Identifying patients who require case management 7National guidelines and evidence-based practice 8Embedding evidence in practice 8Making progress in the management of chronic conditions 9Modernising care in the National Health Service 10Developing case management and care delivery 10Case management in the National Health Service 11Promotion of self-management and self-care 13Partnerships and expectations 13Conclusion 15References 152 Case Management Models: Nationally and Internationally 18Introduction 18The context for case management in the NHS 20Impact of managed care models 21International models of care reviewed 22The Alaskan Medical Service 22Kaiser Permanente (North California) 24Group Health Cooperative (Seattle, Washington) 25HealthPartners (Minnesota) 25Touchpoint Health Plan (Wisconsin) 26Anthem Blue Cross and Blue Shield (Connecticut) 26UnitedHealth Europe Evercare 26Amsterdam HealthCare System (the Netherlands) 27Outcome intervention model (New Zealand) 28National model of chronic disease prevention and control (Australia) 28Guided Care (United States) 28PACE (United States) 28Veterans Affairs (Unites States) 29Improving Chronic Illness Care (Seattle) 29Expanded Chronic Care Model (Canada) 29Pfizer (United States) 29Green Ribbon Health: Medicare in health support (Florida) 30What do these models provide? 30Models in use in England 30Care management in social care 32Case management models in the NHS 32Joint NHS and social care 36Data for case management 38Evaluation 38Conclusion 40References 413 Competencies for Managing Long-Term Conditions 43Introduction 43Development of the competency framework 44What the competencies are expected to deliver 46The competencies: what are they? 46Domain A: advanced clinical nursing practice 47Domain B: leading complex care co-ordination 49Domain C: proactively manage complex long-term conditions 52Domain D: managing cognitive impairment and mental well-being 52Domain E: supporting self-care, self-management and enabling independence 55Domain F: professional practice and leadership 57Domain G: identifying high-risk people, promoting health and preventing ill health 58Domain H: end-of-life care 59Domain I: interagency and partnership working 60What the competencies aim to do 61Developing educational models to develop competencies 62Conclusion 64References 644 Outcomes for Patients – Managing Complex Care 66Introduction 66The areas of competence and deliverables for patients: Leading complex care co-ordination 66Identifying high-risk patients, promoting health and preventing ill health 74Interagency and partnership working 77Conclusion 82References 825 Outcomes for Patients – Advanced Nursing Practice 85Introduction 85Advanced clinical nursing practice 85Proactively manage complex long-term conditions 91Professional practice and leadership 94Managing care at the end of life 97Conclusion 101References 1026 Outcomes of Case Management for Social Care and Older People 105Introduction 105Policy drivers for the care of older people 105Health and social care integration 108Cost of care for older people 109What do people expect in old age and how will these services be commissioned? 111What does case management offer to older people? 112Integrated models of care 114Impact of case management on older people 114Managing resources 118Outcomes for older people 118Conclusions 119References 1207 Outcomes for Patients – Cancer Care and End-of-Life Care 123Introduction 123Gold Standards Framework for Palliative Care 125Integrated Cancer Care Programme 125Preparing for the pilot programmes 127Delivering the pilots 129Programme outcomes 130Case Management and ICCP 131Case management competencies – what can/should patients expect? 132The real need for competencies 137Advanced care planning 139Preferred place of care and delivering choice programmes 140Conclusion 140References 1428 Leadership and Advancing Practice 144Introduction 144What is leadership? 144What does leadership provide? 145Leadership framework in the NHS 146Skills in leadership 147Political understanding and functioning 148Setting targets and delivering outcomes 148Empowerment and influencing 149Levels of competence 150Other leadership frameworks 150What does good leadership do? 153Impact on organisations 153Leadership in case management 154Leadership and change 155Leadership is in every role 156Advanced practice 157Prescribing 158Advanced practice in long-term conditions 159Conclusions 160References 1619 Self-Care and Patient Outcomes 164Introduction 164What is self-care? 164Self-care and practitioners 167Systems for self-care 168Expert Patient Programme 168Effectiveness of self-care programmes 169Promoting self-care: staff role 170Self-care: models 171Self-care: the evidence base 173Using information and technology for self-care 175How do we engage patients in self-care? 179Conclusions 180References 18310 What Does This Mean for Patients? 185Introduction 185Government expectations 186What do patients want from care? 186Reported outcomes from management of long-term conditions 187Modernisation to enable outcomes for users of services 188Do patients really see improvement? 188Understanding the patient experience, how we find out? 190Public Service Agreement targets 192Other assessments of user/patient experiences 192Patient-centred care 195Allowing patients to tell their tale 195Outcomes of care and patient experience 195Experience in case management 197Partnerships with patients: impact on experience 199Quality for patients 200Impact of the provision of information on patients’ views and outcomes 201Conclusions 201References 203Index 207