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Optimising Approaches to Case Management

Harnessing greater benefits across a wider case mix

Written by: Dr Sara Watkin, Medicology Ltd. Published: 2nd June 2010

Case management has been widely introduced as a model for the management of patients with complex needs and at high risk of unplanned admissions as a result of long-term conditions. Defined by the Department of Health as

"A service, led by a community matron or case manager that provides proactive, coordinated care to people who have an intricate mix of health and social care needs. It provides an intense level of care, preventing people from unnecessary admission to hospital and providing more care in the person’s home or community setting. It supports carers by relieving them of having to coordinate services and navigate a range of health and social care systems."

It is hoped that case management, by targeting the 5% of patients who account for 42% of all admissions in the UK, will significantly reduce the secondary care burden.

The key principle core to case management is proactivity rather than reactivity, requiring a bigger picture view of the patients needs (e.g. Mrs Jones’s needs as opposed to her leg ulcer needs) and working with the patient to empower them towards increasingly self care, improving their quality of life and often influencing the disease burden itself. For patients with long-term conditions and complex health needs, case management has resulted in decreased admissions to hospital measured in hospital bed days and improved self care and quality of life. It looks like a win-win.

More results in less
This approach may seem labour intense in the early stages, as rather than thinking of Mrs Jones’s leg ulcer, it is important to consider what endpoint is actually being aimed for, whether this be discharge, no unplanned admissions to hospital or predominantly self care. However, by applying appropriate interventions at this early stage, medical/nursing contact time is ultimately reduced and the approach is associated with higher quality outcomes.

Are there any negatives to case management when undertaken in the way the government initially prescribed? Well as an outsider (I am a Consultant Neonatologist by training), but one with a passion for taking a close look at different services, the simple answer is no. It may initially appear expensive but the savings over time are substantially greater. However, the challenge is in getting community teams to operate in this goal-directed, bigger picture mentality and so halt the more traditional reactionary approach to symptomatic disease.

So where does it all fall down?
In general, case management delivered by community matrons has been nothing but a success story as it involved a whole new type of nurse dealing with a previously unidentified patient group. It is where case management is transferred to other established areas e.g. general community nursing (or old style district nursing) that it struggles. There are 3 main reasons for this:

• “We are too busy” often associated with the perception it takes too long and wastes valuable time
• The culture; we are doing it already, we’ve done it all before, it does not work, it’s just another change for change sake
• We cannot see why it is important, resulting in low motivation and poor attention to the bigger picture

If professionals falling into these groups are to change then it will be on the back of a deeper understanding about why they should. This will include:

• The NHS of 10-15 years ago was not rosy pink. Patient care was reactive, doctorcentred and delivered predominantly in secondary settings. If the NHS is to survive, patients need to be at the centre of their own health, taking responsibility and ensuring valuable healthcare resources are not wasted.
• Reactive care is both unsustainable and does not meet the patient needs
• The NHS cannot survive in its present form. There are not enough resources to meet the needs of a rapidly increasingly elderly population and significant technological innovation, where advanced new drugs for many diseases are just around the corner. We all have to look at how we will work differently to become efficient whilst delivering a high quality patient service.
• If we are not efficient, safe, effective and delivering a great patient experience, competition from both other NHS organisations and the independent sector will mean we will not survive in the new world. It’s a funding issue where there are no second places in the long run.
• If we do not change the way we work, the health are burden will continue to increase and our jobs will become increasingly busy, task-orientated, time intense and ultimately poorly satisfying.

Once the necessity or desire to change is established, we need to build on a “Can Do” attitude as opposed to a “cannot do” state of mind. This is not always easy and so the more we see community matrons leading by example, demonstrating the benefits to patients and carers lives, the more this concept will slowly infiltrate through mainstream nursing and medical practice. We need to get whole teams to recognise time spent up front by “case manages” actively listening and recognising the needs of the whole patient will ultimately save time for all, reducing the task management approach to care which by its very nature is time consuming. However, if we truly get case management right, could the benefits be extended into other aspects of medicine?

Could case management principles be transferred to wider healthcare?
So, can the principles of case management be transferred to other groups such as community nurses in general, GP practice nurses, hospital outreach teams and even acute hospital settings? My answer would be a resounding yes.

The changing population dynamics in the UK, but especially in England, calls for drastic action. Even before the present recession we were already being warned by Lord Darzi that in its present form the NHS was unsustainable. The UK population is predicted to rise from 61 million in 2006 to 71 million in 2031 i.e. a 17% increase over a 25 year period. This increase is predominantly in the over 65s reflecting an increasing life span. With increasing age comes increasing ill health and long-term conditions. Superimpose on this changes in lifestyle choices impacting obesity (and resulting in diabetes, coronary heart disease and now increasingly associated with cancer) drastic action is required. The NHS needs to move away from being a reactive illness management service to a proactive disease and health management organisation. Case management as an approach fits very well with this by being proactive rather than reactive, by developing a clear big picture outlook for all patients at first presentation and working to ensure co-ordination of services. You could call it patient-centred, personal leadership with each patient an individual with their own unique set of healthcare goals and appropriate support. So how might this look in a variety of scenarios:-

Community Nursing
Mrs Jones has had recurrent leg ulcers for 3 years now. The community nurses are concerned that these might be self inflicted as every time they improve and they reduce their visits the ulcers deteriorate. A new community nurse taking a case management approach quickly recognises that despite maximum medical and nursing intervention Mrs Jones ulcers are not going to improve. She is very lonely, she has one son who lives 3 hours away who rarely visits and since her husband died 3 years ago Mrs Jones social life has deteriorated to nothing. She no longer goes out, sits in her chair all day and no longer sleeps in her bed.

With the support of local volunteers employed via the PCT the community nurse organises for Mrs Jones to have regular contact with a lady in her mid 50s who decided to do voluntary work after her own husband died. Slowly Mrs Jones starts going out more, the ulcers no longer deteriorate and 5 months later community nursing can be withdrawn. The volunteer continues to see Mrs Jones 2 days a week for a cup of tea but now Mrs Jones is out the other 3 days at a variety of local community events organised in her village.

General Practice
Mr Smith is significantly overweight with a BMI of 35. He approaches his GP to request bariatric surgery. It is clear that he has not tried any other approach to weight loss in a systematic way. The GP, with the patient’s agreement, refers him to the practice nurse. Together they develop a big picture approach to Mr Smith loosing 4 stone in weight over the following year. The practice nurse co-ordinates a dietician review, referral to a local weight loss group and a regular exercise group designed specifically for people with obesity. She knows, if it is appropriate, she can coordinate other services such as cognitive behavioural therapy for Mr Smith. She organises with the GP for the prescription of a suitable medication such as Orlistat and also shows Mr Smith how to access further information on the NHS Choices website. She keeps in regular contact with Mr Smith both in the surgery and by phone. Over the next 12 months he loses 9stone in weight and no longer needs bariatric surgery.

Secondary care
The key to case management in the secondary sector is (a) to actively consider discharge from the moment a patient is admitted to hospital rather than whether they are ready for discharge and (b) to actively consider factors which might contribute to the patient being readmitted and work to prevent them.

Mrs Brown is admitted to her local hospital with severe confusion. She lives alone, has no family and is reported by neighbours to have been increasingly confused for some months, causing danger leaving the gas on and letting her surroundings become increasingly squalid. Mrs Brown is known to be a heavy drinker. She has had several admissions in the past for detoxification and when not confused had admitted drinking up to 2-3 litres each day of cheap cider. Using a case management approach from the moment of admission the team not only consider her acute health needs as she undergoes detoxification but also her long-term needs as a patient with probable Korsokoff’s dementia struggling to live by herself. By working in this way and liaising closely with social services when Mrs Brown no longer needs the assistance of secondary care, a bed in a nursing home is available for her in the community.

Improvement for the long haul
Ultimately the concepts of case management are not new. The reality is remembering them. In the busy NHS it is easy to be only reactive; treating the immediate problem. To continue to do this means the rapid demise of the NHS as we know it. Drastic but positive action is required. The more proactive we are the less time we will ultimately need to spend. The more we can work with patients to decide on the bigger picture for their own health, the more we will ensure we do the right things at the right time and not simply react to a set of symptoms. This will ultimately result in empowered patients who start to self mange the majority of their care and do not depend on the medical and nursing profession take every decision for them and provide the care decided upon. When we achieve this, we are starting to move back towards sustainability.