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

1 Background to the Implementation of Case Management Modelsfor Chronic Long-Term Conditions within the National HealthService

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 andInternationally

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 mentalwell-being

Domain E: supporting self-care, self-management and enablingindependence

Domain F: professional practice and leadership

Domain G: identifying high-risk people, promoting health andpreventing 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/serviceusers: leading complex care co-ordination

Identifying high-risk patients, promoting health and preventingill health

Interagency and partnership working

Conclusion

References

5 Outcomes for Patients Advanced NursingPractice

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 OlderPeople

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 becommissioned?

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-LifeCare

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 patientsexpect?

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 findout?

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 onpatients /service users views and outcomes

Conclusions

References

Index