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
