Case Management of Long-term Conditions: Principles and Practice for Nurses

The importance of appropriate and effective management of patient with long term chronic conditions cannot be underestimated. Case Management of Long-Term Conditions aims to provide all appropriate practitioners (including nurses, pharmacists, physiotherapists, and 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 clients.

Table of Contents:
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

About the Author :
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.