Case management for long-term conditions

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This article has been subject to peer review

the World Health Organization (WHO), in high-lighting the need for healthcare systems to prevent or manage long-term conditions, claimed that the focus of health care must move away from episodic care of seriously ill patients in hospitals towards continuous care by teams that combine specialist expertise and generalist capabilities (WHO 2002).

National service frameworks encourage better man-agement of single conditions, but the approach they

take is disease-specific, and no such framework has been devised for people with multiple conditions.

South Wales has an ageing population and a history of post-industrial unemployment, which place huge demands on its health and social care systems, so the management of long-term conditions in this area is particularly significant.

In addition, Wales has the highest rates of long-term illnesses such as arthritis, and respiratory and heart conditions in the UK, and these illnesses account for many unnecessary emergency admissions to hospital (Welsh Assembly Government (WAG) 2007) (Box 1).

Some parts of the health service in Wales provide support for people with long-term conditions, for example through well-established primary care teams and networks of other community providers such as pharmacists and therapists (Wilson et al 2005). The care offered by general practices to people with long-term conditions varies across communities, how-ever, despite government efforts to reduce such incon-sistencies (Seddon et al 2001).

As a result, the need to change how long-term con-ditions are managed is urgent (WAG 2007).

The pilot

In 2005, a sample of five Swansea general practices revealed that 3 per cent of patients accounted for 59 per cent of emergency admissions. Many of these admissions were unnecessary, inappropriate and avoid-able. They were due to inappropriate care, a lack of adequate support structures for people with long-term conditions and their carers in the community, and a ten-dency for emergency services to react to patients’ con-ditions rather than offer them preventative strategies.

Welsh Assembly Government (2007) figures show that one in six admissions to hospital, and one in four

Inconsistencies in the management of people with long-term conditions, along with

high numbers of unplanned acute admissions, has led to the implementation of a case

management system across Swansea. deborah thomas explains

Case management for

long-term conditions

Ph ot ol ib ra ry . t hi s pi ct ur e is po se d by a m od el

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emergency admissions, are attributable to long-term conditions. Furthermore, people with multiple long-term conditions often remain in hospital longer than necessary because of the complexity of their care needs (Hudson and Moore 2006).

Social factors, such as those associated with depriv-ation and poverty, contribute to the rise in emergency admissions (Hanlon et al 2000), as do demographic factors such as increasing age (Chan et al 2002), sol it ar iness, bereavement and inadequate social sup-port for widows. In addition, unplanned hospital admission rates are higher among care home residents than in the community (Godden and Pollock 2001).

For many years, patients with multiple long-term conditions and complicated needs have received unco-ordinated and fragmented care. As a result, they have missed out on opportunities to maintain or improve their health, and to avoid frequent or lengthy hospital admissions.

To solve these problems, Swansea Local Health Board (LHB) initiated in April 2005 a long-term, or chronic, conditions management (CCM) pilot project to improve the management of long-term conditions across the area. The initiative built on the findings of pilots in other areas, including the Castlefields Health Centre project, in Cheshire, on the role of social work-ers and district nurses in improving care for older peo-ple (Improvement Found ation 2008), and the Evercare project, in England, on supporting people with long-term conditions (Department of Health (DH) 2005).

It is also in line with the strategic vision for health-care services in England and Wales described in the Wanless Report (DH 2002), in which people are encouraged to live more healthily and become more involved in their own health care.

The steering group

To launch the CCM pilot, a steering group of key stake-holders was set up. The members of this group are listed

in Box 2. For the initial stage of the project, the steering group decided to take a case management approach to improve long-term condition management.

Case management is a method of proactive care delivery in the community that involves identifying people who are at high risk of unplanned admission and who have complex and enduring health and social care needs.

Case managers assess, design and deliver a person-alised care plan for each individual in their case loads, and co-ordinate their patients’ journeys through health and social care services by acting as key work-ers (Hudson and Moore 2006). The main activities involved in case management are listed in Box 3.

Five experienced nurses who wanted to take on autonomous roles in care co-ordination were recruited as case managers through adverts in local GP surgeries and regional newspapers.

These case managers undertook an eight-week induction programme that included education and training in pharmacology and medicines manage-ment, clinical history taking, physical examina-tion skills, familiarisaexamina-tion with local services and end-of-life issues.

Five volunteer general practices were identified and staff at each were asked to select a caseload of patients assessed as being at high risk of unplanned admission.

Box 1. The profile of long-term conditions in Wales

n there is a higher proportion of reported life-limiting long-term illness (23 per cent) compared with england (18 per cent), Northern Ireland (20 per cent) and Scotland (20 per cent).

n one third of adults report having at least one long-term condition.

n two thirds of people over 65 years old report having at least one long-term condition, while one third have multiple long-term conditions. n three quarters of people over 85 years old report having a life-limiting, long-term illness.

n Most commonly reported long-term conditions in Wales are arthritis (14 per cent), respiratory (13 per cent) and heart conditions (9 per cent). National Public health Service for Wales (2005)

Box 2. Members of project steering group

n A community nursing manager, an elderly care consultant doctor and a divisional nurse from secondary care, all from Swansea NhS trust, now part of Abertawe Bro Morgannwg University NhS trust.

n A director of clinical development, service development manager, programme manager and practice development manager, all from Swansea local health Board (lhB). n A local GP.

n A professor of primary care medicine from Cardiff University. n A freelance data analyst hired by Swansea lhB.

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Each of the case managers was then chosen to work with one of these caseloads to prevent unplanned admissions or readmissions.

This initial phase of the project ended in March 2006, when it was evaluated quantitatively and qualitatively.

Quantitative data showed that the number of emerg ency medical admissions among people over 50 years old and elderly care admissions in the pilot practices fell by 9.1 per cent, and that the number of hospital stays lasting more than one night fell by 10.4 per cent (Huws et al 2008).

Qualitative evaluation showed that the case man-agers thought that the care they provided, which was based on diligent assessments and medication reviews, had led to new and more accurate diagnoses, better co-ordination of further care and the tailoring of serv-ices to suit the needs of individuals. This type of care, they said, had not been available previously.

The benefits reported by the patients related to improvements in their quality of life rather than to the prevention of hospital admissions.

The steering group concluded that, in intro-ducing a role for case managers, the pilot enabled more time to be spent on assessing the individual needs of patients who struggle to live independently (Elwyn et al 2008).

The CCM service

After consultation with general practices across Swansea, the CCM service was introduced across the city in two phases during 2006.

Under the scheme, 25 registered nurses, work-ing the equivalent of 23 whole-time staff, and seven healthcare support workers, working the equivalent of

six whole-time staff, are employed by Swansea LHB and are based in 35 GP surgeries.

These 25 case managers and seven support staff work seamlessly across health, social care and volunt-ary care organisations. Each of them has a caseload of up to 50 patients with multiple long-term condi-tions; many of the patients take multiple medications or have had falls. These patients tend to be particularly vulnerable because they have poor control over, and experience frequent exacerbation of, their conditions. Many of them live alone and are isolated socially with little support. The CCM service aims to be pro-active rather than reactive, by empowering them (Box 4).

Swansea CCM service staff pro-actively identify suitable clients for case management from emer-gency admission data sent weekly from Abertawe Bro Morgannwg University NHS Trust. Referrals are also taken from GPs.

To ensure that the profile of the new service was raised among organisations in the local health, social care and voluntary sector communities, the referral criteria was not defined at first. As a result, there was a large number of referrals, many of which were judged inappropriate to the remit of the service.

Latest figures

Data on the number of emergency medical admissions among people over 50 years old and care of the elderly admissions for 2007/08 demonstrate a 10.4 per cent reduction compared with the same period in 2006/07, an 11.0 per cent reduction compared to 2005/06, and an 11.2 per cent reduction compared to 2004/05.

This equates to 1,086 fewer admissions a year among patients registered at the 35 surgeries across Swansea in 2007/08 than in 2004/05, and demon-strates that emergency admissions had reduced further since the pilot project was completed.

Overall, patients are now cared for in the most appropriate places by the most appropriate profess-ionals, and unnecessary emergency admissions are avoided. Emergency medical and elderly care

admiss-Box 4. Aims of the Swansea chronic conditions management service

n to help people manage their complex long-term conditions more effectively and to help them stay healthier for longer.

n to reduce avoidable or long stays in hospital.

n to provide accessible and prompt support for individuals in their homes.

n to maximise or maintain the independence and quality of life of people with complex long-term conditions, their families and their carers.

Box 3. Case management activities

n Creating personalised care plans that are based on need and reflect patients’ choice.

n Providing patients with care in the least intensive but suitable settings.

n Supporting effective primary care.

n Focusing on patients with the highest burden of disease.

n Working in partnership with acute, social and voluntary sector services.

n Implementing integrated care pathways for patients. Adapted from Metcalfe (2005).

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ions in 2007/08 compared with previous years are shown in Table 1.

There have been several recent developments within the CCM service and these are described below.

Telehealth pilot

There are a growing number of technological approaches to support people with long-term condi-tions. These include vital sign-monitoring technolo-gies, lifestyle monitoring, reminder systems, telephone-based care management programmes and kiosks for health and wellbeing.

The Swansea CCM team are undertaking a tele-health pilot, which involves patients using a range of self-monitoring devices covering four main functions, depending on each individual’s condition: blood pres-sure, weight, blood glucose and pulse oximetry.

Falls prevention

Much of the work by healthcare support workers con-cerns the assessment and prevention of falls.

Patients identified as being at high risk of falling were unable to reach community falls classes. For this reason, the CCM service healthcare support work-ers have undertaken a trainer’s course in chair-based exercises (CBEs) to improve posture, joint movement, blood circulation and performance of daily functional actions. These exercises have been shown to help older

people to develop and maintain their independence and mobility.

Service staff now deliver CBE training to patients in their own homes and are considering the delivery of it to people in sheltered housing.

Oxygen assessment

Before the CCM service began, the prescribing of oxy-gen was unco-ordinated. Now, all oxyoxy-gen apart from palliative care oxygen, the prescribing of which remains within the remit of GPs, is prescribed by respiratory nurse specialists after assessment by CCM staff. Around 600 patients in Swansea now receive home oxygen ther-apy in a scheme involving the LHB and Abertawe Bro Morgannwg University NHS Trust.

All patients who may need oxygen are referred to the CCM nurses attached to their GP practices and are reviewed on two separate occasions. If their arterial oxygen saturation levels are less than 92 per cent on both occasions, these patients are referred to the respir-atory nurse specialists at the trust.

Patients are reviewed regularly and, if their oxygen saturation levels are found to be more than 92 per cent, they are referred to the respiratory nurse specialists with a view to stopping oxygen therapy.

This system has ensured that oxygen prescript-ions are more appropriate, and the monthly spend on oxygen across the locality has decreased by £12,000.

Table 1. Comparisons of emergency medical and elderly care admissions between 2004 and 2008

Number of admissions each month over four years Percentage change

2004/05 2005/06 2006/07 2007/08 2004/05-2007/08 2005/06-2007/08 2006/07-2007/08 April 832 834 869 731 -12.1 -12.4 -15.9 May 705 742 830 734 +4.1 -1.1 -11.6 June 786 778 816 726 -7.6 -6.7 -11.0 July 838 736 839 652 -22.2 -11.4 -22.3 August 779 804 759 723 -7.2 -10.1 -4.7 September 773 834 775 634 -18.0 -24.0 -18.2 October 819 836 697 760 -7.2 -9.1 +9.0 November 802 755 752 718 -10.5 -4.9 -4.5 December 828 859 781 746 -9.9 -13.2 -4.5 January 811 781 875 745 -8.1 -4.6 -14.9 February 812 819 808 682 -16.0 -16.7 -15.6 March 902 886 802 750 -16.9 -15.3 -6.5 Total 9,687 9,664 9,603 8,601 -11.2 -11.0 -10.4

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Computer-based information

Informing Healthcare, a WAG programme to improve health services by introducing new ways to store, access and use information, worked with healthcare profes-sionals and data analysis experts to develop a computer-based information tool, called PRISM, that stratifies each person in a practice populat ion into one of four levels according to his or her risk of emerg ency admission.

The information can be used by community nurses and social services staff to provide additional care, to increase support or preventative treatments that help prevent patient deterioration, and to keep people out of hospital.

Anticoagulant monitoring

In August 2007, the prescribing team at Swansea LHB undertook an audit of local patients who use warfa-rin. This found that there were more than 300 such patients who may not have been monitored and that monitoring and prescribing responsibilities had become separated. Consequently, independent prescribers from the CCM service are currently being trained to run anticoagulation clinics while maintaining a reduced patient caseload. A pilot project to test these clinics is being discussed.

Lessons learned

Many lessons have been learned during the develop-ment, piloting and introduction of the Swansea CCM service, and some of these are described here.

Involving key stakeholders as early as possible

This is the single most important lesson learned during the implementation of the CCM service.

The steering group comprised managers from the former Swansea NHS Trust but did not include clin icians such as community nursing staff. This led to confus ion and uncertainty among other clinicians, such as district nurses and health visitors, about the roles of the case managers.

This confusion and uncertainty has diminished as the clinicians have become accustomed to the structure of the service, but such concerns should have been anticipated and thereby prevented.

Raising the profile of the new service

After the service was introduced, the case managers were inundated with referrals, many of them inap-propriate, from health and social care service pro-viders, and from voluntary agencies. As a result, the referral criteria was changed.

Now, patients suitable for case management are identified through hospital admission data and referrals from GPs. Referrals from other care profes-sionals are welcome, however, after assessment of the patients’ clinical records. If the case managers think that patients would not benefit from case management, they inform the referrers.

This system has enabled the case managers to con-centrate on the most vulnerable patients, who are likely to benefit most from the increased support.

Chan dK, Chong r, Basilikas J et al (2002) Survey of major long-term iIlnesses and hospital admissions via the emergency department in a randomized older population in randwick, Australia. Emergency Medicine. 14, 4, 387-392. department of health (2001) Medicines and Older People: Implementing medicines-related aspects of the NSF for older people. www.dh.gov. uk/en/Publicationsandstatistics/Publications/ PublicationsPolicyAndGuidance/dh_4008020 (last accessed: January 29 2009.)

department of health (2002) Securing Our Future Health: Taking a long-term view. The Wanless report. www.dh.gov.uk/en/ Publicationsandstatistics/Publications/

PublicationsPolicyAndGuidance/dh_4009293 (last accessed: January 29 2009.)

department of health (2005) Assessment of the Evercare Programme in England 2003-2004: Executive summary. www.dh.gov.uk/ en/Publicationsandstatistics/Publications/ PublicationsPolicyAndGuidance/dh_4114121 (last accessed: January 29 2009.)

elwyn G, Williams M, roberts C et al (2008) Case management by nurses in primary care: analysis of 73 ‘success stories’. Quality in Primary Care. 16, 2, 75-82.

Godden S, Pollock AM (2001) the use of acute hospital services by elderly residents of nursing

and residential care homes. Health and Social Care in the Community. 9, 6, 367-374.

hanlon P, Walsh d, Whyte BW et al (2000). Influence of biological, behavioural, health service and social risk factors on the trend towards more frequent hospital admissions in an elderly cohort. Health Bulletin. 58, 4, 342-353.

hudson AJ, Moore lJ (2006) A new way of caring for older people in the community. Nursing Standard. 20, 46, 41-47.

huws d, Cashmore d, Newcombe rG et al (2008) Impact of case management by advanced practice nurses in primary References

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Allowing the new service to evolve

The service has changed since its inception and will continue to evolve as patient needs are ident ified. It is essential that staff are aware that change is a fund-amental aspect of long-term conditions management, and that they will need to be flexible and adaptable if they are to meet the changing healthcare needs of the population.

A multidisciplinary approach is important

Effective and efficient long-term conditions manage-ment cannot be implemanage-mented without the contribution of professionals from GPs, intermediate care and com-munity nursing service providers, secondary care col-leagues and the voluntary sector.

By establishing good working relationships with such care professionals, the CCM service has maxi-mised its effectiveness.

Effective medicines management is crucial

Department of Health guidance states that problems with medicines are implicated in between 5 and 17 per cent of hospital admissions (DH 2001). But, among vulnerable people such as those over 75, the figures may be even higher given that 36 per cent of people over 75 take four or more prescribed medicines and 80 per cent take at least one (Medicines Partner-ship 2002).

In Pirmohamed et al’s (2004) prospective analysis of adverse drug reactions in the UK, moreover, the

authors found that such reactions may lead to more than 10,000 deaths a year.

The case managers review patients’ medication as part of their initial assessments, sometimes with pharm-acists if regimens are complicated.

These reviews are in-depth evaluations, each of which is defined as ‘a structured, critical examination of a patient’s med icines with the objective of reaching an agreement with the patient about treatment, opti-mising the impact of medicines, miniopti-mising the number of medication-related problems and reducing waste’ (Medicines Partnership 2002).

Conclusion

Healthcare services depend on the informed choice of patients. They involve the examination of issues such as non-concordance, risk taking, and care processes and pathways to create cultures and philosophies that support patients effectively.

Long-term conditions affect not only the quality of patients’ lives, but also the healthcare services they need, because patients with such conditions are more likely to visit their GPs, be admitted to hospital and remain there for longer.

Effective long-term conditions management offers opportunities for improvements in patient care and serv-ice quality, and for reducing costs. It supports patients in managing their own conditions to the point at which crises or deterioration can be prevented, so that the overall quality of their lives improves

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References

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