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2. Case management for patients with complex long terms conditions and high intensity needs

Key Actions

  1. Identify patients with complex conditions who are most at high risk of unplanned admissions or long term institutionalisation.
  2. Develop the role of community matron in your locality.
  3. Use this information to draw up a plan of how this new service will be introduced and integrated with existing services. This should project the impact case management will have on hospital admissions and lengths of stay.

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.

Steps to implementing case management

As the model of care shows, this high risk group of patients needs not only good management of their specific diseases, but also a holistic overview to be taken of their full health and social care needs. Their care should go beyond the clinical to encompass the full range of factors that affect them such as their ability to maintain personal interests and social contact.

Key to meeting the needs of these patients is a case manager. Patients in this group often have a combination of medical, nursing, pharmacy and social care needs and nurses, as community matrons, are ideally placed to meet the range of needs without fragmenting care. It is recognised that other professionals may also take on a case management role for this group of patients. However, where the clinical needs of these patients are high, we expect that community matrons will take on the case management role.

Step 1: Identifying the most vulnerable patients

Health and social care organisations need to develop ways of identifying patients with the most complex conditions who are most at risk of admission to hospital or institutionalisation. These are the patients who will most benefit from case management.

Health and social care partners will first need to agree the most appropriate criteria for selecting these people, drawing on the good practice already established in different parts of the country. This can happen now. The criteria are likely to take account of:

  • how often a patient is admitted to hospital and the length of their stay;
  • the number of medical and other problems a patient has (co-morbidity);
  • the number of medicines a patient takes (or fails to take and the reasons for not taking them);
  • the number of times a patient consults their GP about their condition, and
  • other high risk factors such as the death of a patient's carer.

Data sources should include GP records and district nursing records, as well as hospital discharge records.

Health and social care organisations need to ensure they do not overlook any 'hidden populations' of vulnerable patients. Many of the areas which have been piloting case management using nurses have identified high-risk patients who tended to be known to one part of the service but were not known, or being actively managed by, the whole care system. For example, only 24% of patients treated under the NHS-adapted Evercare pilots were on active district nursing caseloads, and only 35% were known to social services. (Evercare is one model of case management. Health and social care organisations should adopt the principles of case management (adapted to local NHS and social care circumstances) set out in this document rather than any particular model.) The pilots have highlighted that data about high-risk patients does exist in PCT systems, but not in a ready form. This suggests a need for more systematic tools and processes for extracting data and enhanced data management skills within PCTs.

Increasingly we will see software developments internally and externally to the NHS to support this task. Analysis shows that identifying high risk patients may not be static; many will recover. Similarly, other high risk patients will emerge. The Department will work with Strategic Health Authorities to identify whether to specify one approach to be used consistently across the country to allow progress to be compared. We will provide an update to this document if this is the case. In the meantime, health and social care partners should use the above criteria to identify most at risk patients.

Case Study: Castlefields Health Centre in Runcorn

Here a nurse, working closely with a social worker, considers patients eligible for case management if they are over 65 and meet at least three of the following criteria:

  • four or more active long term conditions;
  • four or more medicines, prescribed for six months or more;
  • two or more hospital admissions, not necessarily as an emergency, in the past 12 months;
  • two or more A&E attendances in the past 12 months;
  • significant impairment in one or more major activity involved in daily living;
  • significant impairment in one or more of the instrumental activities of living, particularly where no support systems are in place;
  • older people in the top 3% of frequent visitors to the practice;
  • older people who have had two or more outpatient appointments;
  • older people whose total stay in hospital exceeded four weeks in a year;
  • older people whose social work contact exceeded four assessment visits in each three month period, and
  • older people whose prescribing costs exceeded £100 per month.

Case study: NHS Evercare Pilots

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Here, each PCT identified people 65+ who had two or more unplanned hospital admissions in the last 13 months (from 1 Jan 2002 to 31 Jan 2003).

Additional criteria were developed to nominate patients into the high-risk caseload of the nurses who were the case managers. GPs were given nomination criteria as guidelines for the inclusion of more patients in the high-risk caseload Any one of the following four criteria were reasons to nominate a person into the high-risk caseload:

  • recent exacerbation or decompensation of chronic illness (within last 90 days);
  • recent falls: >2 falls in 2 months;
  • recently bereaved and at risk of medical decline (death of a spouse or family member in past 6 months), and
  • cognitively impaired, living alone, medically unstable, and high intensity social service package.

Step 2: Develop the community matron role

Community matrons are likely to have caseloads of around 50-80 patients with the most complex needs and who require clinical intervention as well as care co-ordination. They will work across health and social care services and the voluntary sector, so that this group of patients receives services that are integrated and complementary. Whether they work from the PCT, general practice or a hospital, community matrons need to have close working relationships with general practice, hospital wards and local social services teams.

Community matrons can come from any branch of nursing. However district nurses are likely to be the single largest group who will most easily make the transition. Where this happens, arrangements will need to be in place to enhance the skills of other members of the district nursing team, including unqualified staff, so they can increase their own capacity. Community matrons may also be drawn from hospitals where experienced senior nurses have skills that can be developed for a community case manager role. Community matrons are expected to be both independent and supplementary prescribers. Steps will need to be taken to boost the numbers of qualified nurses entering primary care. Examples of how to do this are shown in the Flexible Entry to Primary Care Nursing Project Report (DH 2004).

Developing the competencies to become a community matron needs to be in keeping with the knowledge and skills framework and the skills escalator. The community matron role profile will be made available in this form.

A self assessment tool will be made available to support nurses from both primary and secondary care services prepare to undertake the community matron role. PCTs will be able to commission local education and training based on the competencies provided by the knowledge and skills framework and the information provided by nurses completing the self assessment exercise.

A further publication providing guidance on the nursing contribution to long term conditions and the community matron role will also be available shortly.

The role of a community matron


  • Work collaboratively with all professionals, carers and relatives to understand all aspects of the patient's physical, emotional and social situation.
  • Develop a personalised care plan with the patient, carers, relatives and health and social care professionals, based on a full assessment of medical, nursing and care needs. The plan includes preventative measures and anticipates any future needs the patient may have.
  • Keep in touch with the patient and monitor their condition regularly. This may be done by home visits or by telephone contact.
  • Initiate action if required, such as ordering tests or prescribing.
  • Update the patient's medical records, including medicines review, and inform other professionals about changes in condition.
  • Liaise with other local agencies such as social services and the voluntary and community sectors, to mobilise resources as they are needed.
  • Teach carers and relatives to recognise subtle changes in the patient's condition that could lead to an acute deterioration in their health, and to call for help.
  • Secure additional support as needed, for example, from home care, intermediate care or palliative care teams, or geriatricians.
  • Maintain contact with the patient if s/he is admitted to hospital and give the unit treating the patient the information they need to ensure integrated and consistent care.

Community matrons will need to be competent in:

  • care co-ordination and case management (brokerage and provision);
  • physical examination and history taking, diagnosis and treatment planning;
  • managing cognitive impairment;
  • using population and individual information to support decision making;
  • independent and supplementary prescribing and medicines management;
  • interagency and partnership working;
  • management of long-term conditions (particularly the interplay between multiple diseases);
  • working in the home and community settings;
  • supporting self managed care;
  • managing care at the end of life;
  • prevention and health promotion, and
  • advanced level professional practice, including self directed learning, managing risk, autonomous practice, higher level communications skills.

Step 3: Carrying out thorough assessments - care planning

Once those patients most at risk have been identified, the community matron should work with them and their carers to carry out a comprehensive assessment, ie physical, social and psychological, of their current and future health and social care needs and wishes. The community matron will then draw up a care plan to reflect the personal needs and aspirations of the patient (and their carer(s)). This plan will be agreed between the patient and the community matron on behalf of the local health, social care and other agencies involved.

For many older people this approach will build on the single assessment process.

The care plan should set out the patient's agreed health objectives and care needs, including what the individual can contribute towards their own self care, and what each professional and agency will do to help them meet these. It will include preventive and health promotion actions (such as avoiding accidents, reducing infection or nutrition).

It will be owned by the individual and be reviewed regularly by the community matron in partnership with the individual (and their carer(s)). These reviews will evaluate outcomes and identify changes in the needs and wishes of the individual (and their carers).

Step 4: Co-ordinating care and services

The community matron should act as a fixed point for the patient, taking clinical responsibility for their care and co-ordinating the contribution of the different professionals who can help, anticipate and deal with their problems before they lead to worsening health or well-being.

Systematic tools and processes should be in place to help community matrons in their work. These should include:

  • systems enabling them to access care for their patients quickly, such as ordering tests and investigations and mobilising social care services;
  • clinical risk assessment involving patients and carers;
  • processes for informing them if a high-risk patient has been admitted to hospital so they can begin planning for their discharge; and
  • processes, involving primary, secondary and social care, for reviewing avoidable admissions.

The community matron should work with hospital discharge teams to ensure the patient's discharge from hospital is smooth. The patient and their carer should be actively involved in this at all stages. Appropriate care needs to be in place to ensure the patient goes to the right setting to ensure their continued recuperation and rehabilitation. The community matron should make effective use of transitional and intermediate care services so that existing acute hospital capacity is used appropriately.

Supportive and palliative care: the community matron should secure additional support where needed. This might include access to a comprehensive range of rehabilitation advice and support. For people in advanced stages, this might also include access to a comprehensive range of palliative care services which provide appropriate symptom control, pain relief and meet the needs for personal, social, psychological and spiritual support.

Action by Health communities

Health communities should draw up a detailed local plan of how this new case management service will be introduced, how it will integrate with existing services, and how rapid progress can be made in both reducing admissions and lengths of stay. Key steps to assist health communities to take this forward are set out at Annex 1.

Case Study: Case management in North West London

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In just one year, an 83-year-old woman in London suffered 57 falls and came into contact with 14 different health and social care professionals.

It was only after referral to a case management pilot service at Kensington & Chelsea PCT - part of the London Older People's Service Development Programme (LOPSDP) - that some of the underlying and strikingly simple causes came to light. A lop-sided mattress causing her to roll out of bed explained why most of her falls happened in her bedroom, and a dead battery in her doorbell accounted for the numerous times she missed her weekly pharmacy delivery.

North West London SHA has been keen to see multi-disciplinary case management (CM) continue.

Their research programme showed:

  • case management could release significant capacity in local inpatient services
  • leading to reductions of between 7.5% and 16.6% in occupied bed days in medical specialties;
  • for each PCT this capacity would be worth up to £1.15 million per year, and
  • indicative costs of setting up a CM service was around £173,000.

'Many of the existing models of case management are health focused,' says Steve Arnold. 'But for many, chronic disease is not about a single condition, it's about lots of difficulties combined to create a vulnerable state.'

Among several projects now underway, two of the SHA's eight PCTs are linking case management techniques into their district nursing services. An inter-disciplinary Care Co-ordination Team has also been set up in Brent.

Funded by Brent Teaching PCT, the five-strong team manages a caseload of vulnerable older people across acute and community health, social and voluntary care, building integrated and user-focused care plans.

The National Primary Care Contracting Collaborative - UNIQUE CARE Programme

The National Primary Care Contracting Collaborative (NPCCC) has recently commenced with a key focus on improving the care of patients with a long term condition. A major element of this programme has been the development of 'Unique Care'. This approach to practice-based management of individual patients takes an intensive, co-ordinated approach to their unique health and social care needs. The key factor is bringing together health care and social services to respond jointly to the needs of patients.

All referrals are directed to a care team comprising of a social worker and a district nurse serving a practice's or a cluster of practices' population of over sixty-fives. This case management approach means any long term condition patient admitted to hospital for an unplanned admission is followed up in the hospital by the primary care team to ensure continuity of care and to facilitate early, safe discharge. The approach fits within the development of the community matron role and the emphasis on case management of patients with the greatest needs.

In keeping with the emphasis in the NHS and Social Care Long Term Conditions Model the NPDT are working with practices to identify patients of potentially high need before they are referred for assessment or experience an acute admission. Using locally agreed criteria including number of chronic diseases, previous admission, social circumstances, number of medications etc., patients are identified for assessment by the care team.

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