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Case management

  • Last modified date:
    18 May 2007

As patients develop multiple long term conditions, their care becomes disproportionately complex and can be difficult for them and the health and social care system to manage. Such patients have an intricate mix of health and social care difficulties. Because of their vulnerability, simple problems can make their condition deteriorate rapidly, putting them at high risk of unplanned hospital admissions or long term institutionalisation. This is often older people, but could also include children and patients with complex neurological conditions or mental health problems.

Evidence has shown that intensive, on-going and personalised case management can improve the quality of life and outcomes for these patients, dramatically reducing emergency admissions and enabling patients who are admitted to return home more quickly.

For this reason, the introduction of community matrons applying a case management approach will play a significant role in helping local health communities achieve the PSA target for improving care for patients with long term conditions, and in reducing the use of emergency bed days by 5% by 2008. Case management is also the first step to creating an effective delivery system and implementing the wider NHS and Social Care Long Term Conditions Model

Patients At Risk of Re-hospitalisation (PARR) Case Finding Tool.

As part of the Department of Health's long term conditions strategy, the Department, Essex Strategic Health Authority (on behalf of all the 28 SHAs in England), and the Modernisation Agency have commissioned the King's Fund to develop a software tool for use by Primary Care Trusts (PCTs) to systematically identify patients who are at high risk in the future of readmission to hospital via emergency admissions. The Patients At Risk of Re-hospitalisation (PARR) Case Finding Tool became nationally available from September 2005.

Once PCTs have identified their high risk patients, referred to as Very High Intensity Users (VHIUs), they will be offered care using a case management approach to provide more proactive, co-ordinated and joined-up care in community settings.  Delivery of care for these patients will be led using a Case Manager, usually a community matron.  Evidence at home and abroad has shown that intensive, on-going and personalised case management for patients with multiple or single complex conditions can improve their quality of life and outcomes, thus dramatically reducing emergency hospital admissions.

The tool operates in a relatively simple database in Microsoft Access and it is freely available to all healthcare managers and healthcare professionals within the NHS who wish to use it. It extracts information from Hospital Episode Statistics (HES) data using criteria that are known to be risk factors in future admissions to hospital.


Key enhancements have been made to the original PARR algorithm. The tool has been developed further to take account of feedback from users, this is version PARR 1. It has a faster running time, is more user friendly and has an easier de-encryption function. This version focuses on triggering admissions for specific reference conditions, including congestive heart disease, diabetes and COPD, which represent around 20-25% of all emergency medical admissions.

A further modified version of the algorithm has also been created, PARR 2 and uses any emergency admission as trigger - this version does not include the reference conditions used in PARR 1. As PARR 2 therefore focuses on a larger number of patients, it identifies more patients within each risk threshold, but because a set of criteria has been removed, it will have a slightly higher false positive rate. By removing the reference conditions criteria, PARR 2 may facilitate the identification of tools in 'real time'. Running the tool in 'real time' has the advantage of identifying patients who are still hospitalised following an emergency admission, therefore offering the case management service to those patients who need it at a much earlier stage.

PARR 1 and PARR 2 are contained in the software package called PARR+, which was launched on 1 February 2006 and is the most up to date version. PARR+ is free to use for NHS organisations and can be downloaded from the links.

NHS organisations may initially wish to run both PARR 1 and PARR 2 and compare the findings of each prior to deciding which version is the most appropriate for their local needs.

Note. These two tools are enhancements to the current hospital episode statistics (HES) based algorithm and not the model that is being developed which will combine both hospital and community data. The combined algorithm should become available to the NHS later in the year and will have the added power of predicting emerging risk of hospital readmission for those patients who have not yet experienced a recent hospital admission.

The Combined Model

The Combined Model, the final phase of work undertaken by the Kings Fund, was officially released on 13th December 2006.  The Model uses a more powerful combination of hospital and community data to increase predictive power.  As it has an important added benefit of identifying people who have never had an admission but are predicted to be future high users of secondary care services, it means that relevant interventions can be provided at a much earlier stage, improving care for those people and preventing or slowing down deterioration.

We released the Combined Predictive Risk Model at the Long Term Condition Case Finding Conference held on 13th December 2006.  The aim of the conference was to show how risk prediction and the use of data can be used to deliver improvements in care, business modelling and better commissioning.  A further aim of the conference was to stimulate discussion around how risk stratification and case management fit not only with commissioning but the wider health reform agenda.

Identifying emerging risk will allow NHS organisations to plan interventions to minimise/prevent emergency admissions.

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