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

Janet Snoddon



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Wiley-Blackwell (an imprint of John Wiley & Sons Ltd)
16 March 2010
Diseases & disorders; Nursing
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.
By:   Janet Snoddon
Imprint:   Wiley-Blackwell (an imprint of John Wiley & Sons Ltd)
Country of Publication:   United Kingdom
Dimensions:   Height: 244mm,  Width: 171mm,  Spine: 13mm
Weight:   406g
ISBN:   9781405180054
ISBN 10:   1405180056
Pages:   224
Publication Date:   16 March 2010
Audience:   Professional and scholarly ,  Undergraduate
Format:   Paperback
Publisher's Status:   Active

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


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 andInternationally


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




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 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



4 Outcomes for Patients Managing Complex Care


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



5 Outcomes for Patients Advanced NursingPractice


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 OlderPeople


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



7 Outcomes for Patients Cancer Care and End-of-LifeCare


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



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


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: models

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?


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




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.

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