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.
Case Management of Long Term Conditions aims to provide all appropriate practitioners across all the professions (nurses, pharmacists, physiotherapists including social care practitioners) who might be involved in delivery of proactive case management with a practical understanding of how their knowledge and skills can be utilised to improve outcomes for people with Chronic Long Term Conditions. The text contains some broad reflections on care and service delivery based on reviews of evidence and views from clinicians in the use of these skills and competencies to deliver improved outcomes for these clients.
Table of Contents
1 Background to the Implementation of Case Management Models for Chronic Long-Term Conditions within the National Health Service
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
2 Case Management Models: Nationally and Internationally
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)
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
3 Competencies for Managing Long-Term Conditions
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
4 Outcomes for Patients – Managing Complex Care
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
5 Outcomes for Patients – Advanced Nursing Practice
Advanced clinical nursing practice
Proactively manage complex long-term conditions
Professional practice and leadership
Managing care at the end of life
6 Outcomes of Case Management for Social Care and Older People
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
Outcomes for older people
7 Outcomes for Patients – Cancer Care and End-of-Life Care
Gold Standards Framework for Palliative Care
Integrated Cancer Care Programme
Preparing for the pilot programmes
Delivering the pilots
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
8 Leadership and Advancing Practice
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 in long-term conditions
9 Self Care and Patient Outcomes
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: the evidence base
Using information and technology for self-care
How do we engage patients in self-care?
10 What Does this Mean for Patients?
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
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