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.

The importance of appropriate and effective management of patient with long term chronic conditions cannot be underestimated, and both the Department of Health and the public are expecting much from the improvements and changes outlined in the recently published review by Lord Darzi.

Introduction 1 Background to the Implementation of Case Management Models for Chronic Long-Term Conditions within the National Health Service Introduction Primary care management of long-term conditions How management approaches have been developed Developing and delivering care Future of care The impact and cost of chronic disease Identifying patients who require case management National guidelines and evidence-based practice Embedding evidence in practice Making progress in the management of chronic conditions Modernising care in the National Health Service Developing case management and care delivery Case management in the National Health Service Promotion of self-management and self-care Partnerships and expectations Conclusion References 2 Case Management Models: Nationally and Internationally Introduction The context for case management in the NHS Impact of managed care models International models of care reviewed The Alaskan Medical Service Kaiser Permanente (North California) Group Health Cooperative (Seattle, Washington) HealthPartners (Minnesota) Touchpoint Health Plan (Wisconsin) Anthem Blue Cross and Blue Shield (Connecticut) UnitedHealth Europe Evercare Amsterdam HealthCare System (the Netherlands) Outcome intervention model (New Zealand) National model of chronic disease prevention and control (Australia) Guided Care (United States) PACE (United States) Veterans Affairs (Unites States) Improving Chronic Illness Care (Seattle) Expanded Chronic Care Model (Canada) Pfizer (United States) Green Ribbon Health: Medicare in health support What do these models provide? Models in use in England Care management in social care Case management models in the NHS Joint NHS and social care Data for case management Evaluation Conclusion References 3 Competencies for Managing Long-Term Conditions Introduction Development of the competency framework What the competencies are expected to deliver The competencies: what are they? Domain A: advanced clinical nursing practice Domain B: leading complex care co-ordination Domain C: proactively manage complex long-term conditions Domain D: managing cognitive impairment and mental well-being Domain E: supporting self-care, self-management and enabling independence Domain F: professional practice and leadership Domain G: identifying high-risk people, promoting health and preventing ill health Domain H: end-of-life care Domain I: interagency and partnership working What the competencies aim to do Developing educational models to develop competencies Conclusion References 4 Outcomes for Patients - Managing Complex Care Introduction The areas of competence and deliverables for patients/service users: leading complex care co-ordination Identifying high-risk patients, promoting health and preventing ill health Interagency and partnership working Conclusion References 5 Outcomes for Patients - Advanced Nursing Practice Introduction Advanced clinical nursing practice Proactively manage complex long-term conditions Professional practice and leadership Managing care at the end of life Conclusion References 6 Outcomes of Case Management for Social Care and Older People Introduction Policy drivers for the care of older people Health and social care integration Cost of care for older people What do people expect in old age and how will these services be commissioned? What does case management offer to older people? Integrated models of care Impact of case management on older people Managing resources Outcomes for older people Conclusions References 7 Outcomes for Patients - Cancer Care and End-of-Life Care Introduction Gold Standards Framework for Palliative Care Integrated Cancer Care Programme Preparing for the pilot programmes Delivering the pilots Programme outcomes Case Management and ICCP Case management competencies - what can/should patients expect? The real need for competencies Advanced care planning Preferred place of care and delivering choice programmes Conclusion References 8 Leadership and Advancing Practice Introduction What is leadership? What does leadership provide? Leadership framework in the NHS Skills in leadership Political understanding and functioning Setting targets and delivering outcomes Empowerment and influencing Levels of competence Other leadership frameworks What does good leadership do? Impact on organisations Leadership in case management Leadership and change Leadership is in every role Advanced practice Prescribing Advanced practice in long-term conditions Conclusions References 9 Self Care and Patient Outcomes Introduction What is self-care? Self-care and practitioners Systems for self-care Expert Patient Programme Effectiveness of self-care programmes Promoting self-care: staff role Self-care: models Self-care: the evidence base Using information and technology for self-care How do we engage patients in self-care? Conclusions References 10 What Does this Mean for Patients? Introduction Government expectations What do patients/service users want from care? Reported outcomes from management of long-term conditions Modernisation to enable outcomes for users of services Do patients really see improvement? Understanding the patient/service user experience, how we find out? Public Service Agreement targets Other assessments of user/patient experiences Patient-centred care Allowing patients to tell their tale Outcomes of care and patient experience Experience in case management Partnerships with patients: impact on experience Quality for patients/service users Impact of the provision of information on patients'/service users' views and outcomes Conclusions References Index