INTEGRATED HEALTHCARE
Dr Nick Goodwin, Senior Fellow at health think tank The King’s Fund, discusses the practicalities of the shift to community-based care.
It
is no secret that the growing numbers of older people, and the related num-
bers of people with complex and long-term care needs, will absorb by far the largest share of health and social care budgets over the next decade and beyond.
In order to meet this challenge, care sys- tems internationally are seeking new ways to better co-ordinate and integrate services around the needs of patients and service users. In so doing, they are attempting to improve care experiences and care out- comes whilst simultaneously seeking to reduce the utilisation of expensive facilities in hospitals and/or nursing homes.
Case management has become a core component of this strategy. It takes many forms, but primarily represents a targeted, community-based and pro-active approach to care that involves case finding, assess- ment, care planning, and care co-ordina- tion.
In England, the approach has primarily been taken forward by community matrons – specially trained nurses often working alongside primary care practices managing caseloads of typically 50-60 individuals re- garded as ‘at risk’ of an emergency admis- sion to hospital. Programmes can focus on the management of specific diseases, such as diabetes or respiratory illness, though most often they are generic schemes deal- ing with individuals with complex condi- tions and needs.
The evidence for the impact of case man- agement, however, is decidedly mixed. There remain lingering doubts amongst commissioners about the wisdom of in- vesting in case management, as previous high-profile approaches have not always demonstrated positive results. For exam- ple, the application of the Evercare model of intensive nurse-led case management in the NHS in the early 2000s was found not to be cost-effective, whilst the community matron model has also failed to demon- strate universal success in terms of improv- ing the care experiences of users.1
However, it would be wrong to conclude from such experiences of case management that the approach itself is flawed. There is ample evidence from around the world to
suggest that the approach can work. The problem appears to be that case manage- ment will not deliver better care for pa- tients and produce cost savings unless they are well designed, involve appropriately and professionally trained case managers and teams, and be embedded in a wider system of care that supports and values in- tegrated and co-ordinated care.
The King’s Fund’s recent report on case management addresses those key factors that are linked to its successful implemen- tation.1
These include: • Assigned accountability of an individual (such as a nurse) or team for the patient being case-managed, in order to pro-
vide continuity in how patients access services but also ensure a single line of responsibility for the care and services that person receives regardless of where in the system they are receiving care;
• Clarity about the role of the case manag- ers and support to ensure they have the right clinical skills and managerial com- petencies;
• Accurate case finding to ensure interven- tions are targeting patients with defined care needs;
• Appropriate caseloads to ensure that pa- tients are receiving optimal care;
• A single point of access for assessment and a joint care plan;
• Continuity of care to reduce the risk of an unplanned admission to hospital;
• Self-care, to empower patients to man- age their own conditions and to not be- come dependent on the care system;
• Integrated health and social care teams delivering services jointly;
• Information systems that support com- munication, and data that is used pro- actively to drive quality improvements.
Perhaps most importantly, case manage- ment will not succeed unless it is part of a wider programme of care in which multi- ple strategies are employed to co-ordinate care. This includes good access to an ex- tended range of primary care services, in- vestment in health promotion and primary prevention, and co-ordinating community- based packages of social care to enable re- habilitation and re-ablement.
Given the poor levels of care co-ordination that currently exist in our health and social care system, leading to poor care experi- ences and fuelling unnecessary expendi- ture, it is imperative that services become redesigned and integrated around the needs of individuals. Where designed well, case management will have an important part to play in this strategy.
Reference 1. Ross S, Curry N, Goodwin N (2011) ‘Case management. What it is and how it can best be implemented.’ London: The King’s Fund. Available at:
www.kingsfund.org.uk/ publications/case_manage-
ment.html
Dr Nick Goodwin
FOR MORE INFORMATION Visit www
national health executive Jan/Feb 12 | 31
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