Based on learning outcomes this assignment will critically analyse a case management approach and how it is applied to community practise. It will look at the history of case management and indentify some of the models that exist. This assignment will also demonstrate the different skills the district nurse users to case manage.
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The term ‘Case Management’ came from America, where it advanced, within a social care environment (Hutt et al, 2004). It was introduced in the 1950’s in Northern America for patients with Mental Health needs. Although the term has been around for this amount of time there is no definitive definition of the term ‘Case Management’ (Lee et al, 1998).
Case management to me is best described by the following two authors. Evans et al (2005), patients with complex health care needs require ongoing assessment, planning, implementation, monitoring and evaluation in the provision of proactive care. And NHS (2005), states that patients no matter what their state of mind should be consulted in the way they receive care due to their own knowledge regarding themselves and the impact it has on their lives. Although these definitions are broad they can be applied to other needs in different settings
Care Management can also be atoned to meaning the same as Case Management (Bergen, 2003). In the UK Care Management began with the publication of the white paper ‘Caring for People’ Department of Health (DH, 1989). This paper pledges to provide appropriate assessment alongside good case management. The NHS and community care act, (1990) centres more on care managers from social services rather than focusing on health “assuming that it is the responsibility of social services” (Bergen 2003).
The term case management can be used to explain a number of rolls such as key worker; a key worker could be a nurse, district nurse, case manager, community matron or social worker. Either of these key workers organizes and coordinates patient care and improves quality of life and outcome for these patients which in turn reduce admissions and speeds up discharge (DH, 2005).
Case management has no single model Beardshaw and Towel (Kings Fund, 1990) show three case management frameworks, the Brokerage framework, which supports matching the service to the needs of the individual. The Social Entrepreneurship Framework looks at budgets to provide care packages to the individual, and the Extension framework, which is most reflected in the role of the district nurse, as it focuses on the key worker / care coordinator role in arranging, providing and monitoring care of the individual.
The National Service Framework (NSF) For Older People (DH, 2001) stated that the management of long term conditions should follow a specific standard to be completely effective. After this was liberating the talents, helping primary care trusts and nurses deliver the NHS plan (DH, 2002) which identifies the role change of nurses working in a community service. It is suggested by Robinson, (2005) that district nurses are perfectly placed to take on the role of a case manager due to the fact they already have the necessary assessment skills needed for the job.
There are 6 core elements of case management, competences framework. These are case finding / screening, assessment, care planning, implementation and management and finally monitoring and review. These core elements are carried out by the district nurse on a daily basis and would be forward thinking in checking the palliative care register, for recently diagnosed patients, working in partnership with all the team.
The are various frameworks that have been developed, these are Supporting people with long term conditions (2005), Case management competencies framework (2005), Our health our care our say, a new direction for community services (2006), Lord Darzi interim report (2007), High quality care for all NHS stage review final report (2008) and High quality care for all our journey so far (2009) to name but a few.
The aims of all these frameworks are to better the management of patients that suffer from a long term condition or chronic disease through coordinating and providing care to patients within their home environment. The patient will receive a high standard of care whilst reducing hospital admissions.
The Department of Health (DH, 2008) States a chronic disease is a condition which as present, with current medication, can only be controlled and not cured. A patient suffering from a chronic illness has a complete change in their lifestyle and will not return to what they see as “normal” (DH, 2008). Due to an increase in the length of time people are living, more people are having medical conditions that they will have to live with during that lifetime. These long term conditions are becoming more common and the ability to manage the needs of the patient is an integral part of healthcare today.
The term long term conditions is greatly preferred to the terms chronic disease / illness and is more commonly used. The amount of elderly people within England is constantly rising and it is believed that by the year 2026 20% of the population will be aged 65 or over and between 1995 and 2025 the number of people over 80 will of increased by 50% and the over 90 by 100% (Wannless, D, ).
All case management models that have been covered in government white papers have all been piloted, incorporated or put into practise in the UK. These include Castlefields, Evercare, Parr, Kaiser, Permanente and Unique (DH, 2005). The author of this assignment has had discussions with other people in her area of work, including community matrons, who are more comfortable with the Evercare model but these models are by no means universally used they have taken on different approaches and aspects of each model and tailored them to the needs of the individual with the long term condition. For the purpose of this assignment the Evercare model will be used.
It is understood the Evercare model is a proactive way to managing care for people with long term conditions. The Kaiser model looks to integrate services and removing the divisions between primary and secondary care for all no matter what stage on the Kaiser pyramid they are where the Evercare model specifically looks at those people who have a high risk of admission to hospital. The DH (2005a) studied methods from the United States of America for example Kaiser Permanente on managing chronic illness especially long tern conditions which are categorised into three levels depending on individual requirements. Level one is made up of patients who look after there condition themselves but would benefit from having information and support readily at hand to allow them to manage it better.
Level two are for patients who require specialist input from such as multidisciplinary teams to alleviate the risk of complications and the problem advancing. Level three is for patients who require most help and have more complex and enduring requirements that would gain advantage from case management (DH, 2004).
Patients who are level two and three suffer from conditions like Diabetes Mellitus which is included in the General Medical Services (GMS) framework, which means they will be receiving monitored care from multiple practices. Practice Nurses are heavily involved in the provision of this care and managing the care of diabetic patients who are physically able to attend their local surgery. Housebound patients may not be able to receive this standard of care and this is where the District Nurse comes in as they are in an ideal position to provide the same care to housebound patients that they would receive when attending surgery. They can use a multidisciplinary approach to diabetes management that incorporates a psychosocial as well as a clinical management of living with diabetes (The British Diabetic Association, 2005).
Evercare’s main focus is to integrate social and health care to provide better care for the individual and get better conclusions for the patients through collaborative working between doctors and nurses using skills and partnership working. The Evercare model has been implemented into nine primary care trusts within England and after evaluation has been found to successfully recognise vulnerable older people, provide preventative care and cater care to the needs of the patient (Evercare, 2003).
Liberating the talents (DH, 2002) backs the advancements in nursing rolls within the NHS regarding a nurse led approach to care. Primary Care Trusts have changed greatly whilst implementing these changes keeping in line with the NHS. By switching the focus of this care from the hospital to the community, the providers of community care have changed the way they run their service and have employed community matrons or case managers to manage the care of long term conditions.
The NHS Plan (2004b) states there will be 3000 community matrons put in place to care for around 25,000 patients with case management skills to care for LTC sufferers.
The District Nurse will provide a vital part in the provisions of this national target. The aim is by case managing patients with complex requirements the community matron or district nurse will allow them to remain at home for throughout their care.
A community matron is someone who has the experience, knowledge and the ability to case manage patients who strain resources in healthcare whilst allowing the patients to stay at home and have more input regarding their care The NHS plan (DH, 2004).
The District Nurse is in the ideal position to undertake this work due to the fact they are use to delivering this care in a wide range of settings. They are will placed to provide education, promotion, holistic assessment and care management of patients with long term conditions. Litaker and Moin, (2003) undertook a study which shows that long term condition sufferers have less problems with their condition which it turn lessens hospital admissions when they have District Nurses managing their care. District Nurses care for patients who have co morbidities or suffer from more than one long term condition. Through providing care for this section of patients supports the case management model of care (DH, 2007).
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Case management is considered to be they best way of bringing together the care and treatments required to manage patients with complex long term conditions. “There is a clear relationship between the single assessment process and case management” (DH, 2005). On the other hand case management covers a wide section of skills and techniques. The skills and knowledge required by the District Nurse, identified by Evercare, are not dissimilar to the ones identified in the case management competencies framework.
These are B-I, (DH, 2005) Domaine A which is Advanced Clinical Nursing Practice which a community matron must have when they undertake the role of nurse prescriber and advanced assessment skills. The District Nurse can undertake this training but is dependant on the organisation and funding.
Domain B, Leading Complex Care Co-ordination, this is carried out by the District Nurse on a daily basis through proactively coordinating and arranging complex care packages, managing patients care, reviewing the patients care requirements, liaising with different multidisciplinary teams and, through using other alternatives like respite placement and looking at the ‘bigger picture’, reducing hospital admissions. Domain C, being proactive in the management of long term conditions enabling the patient to be included in the decision making regarding care and where they have the treatment. Domain D, the management of Cognitive Impairment and Mental Well Being. The District Nurse come across various patients who have different mental health problems and have a knowledge and skills to take notice of signs of deterioration and making referrals to the right people. Domain E, Supporting Self Care, Self Management and Enabling Independence, the District Nurse provide dignity and choice through support and encouragement of the patients allowing them to be more independent. Domain F, Professional Practice and Leadership, the District Nurse, just like any other health care professional, are accountable for their own competencies and developments in evidence based practise. District Nurses are managers and have leadership qualities and collaborative working skills as stated in the Nursing and Midwifery Council code (NMC, 2008). Domain G, identifying High Risk Patients, Promoting Health and Preventing Ill Health, District Nurses, on a daily basis, promote and prevent the deterioration of ill health of high risk patients on their case load. Domain H, Managing Care at the End of Life, this area occurs in a high amount of the District Nurse’s case load. They provide advice and support to the patient and their families following the Liverpool Care Pathway, working in collaboration with Macmillan nurses. Domain I, Interagency and Partnership Working, the District Nurse is aware of available services within her area across different organisations and professional boundaries.
AS identified by the Community District Nursing Association (CDNA, 2007) there are various principles that a District Nurse can give to providing better health that reduces the effects ill health can bring. There are many principles of District Nursing which show off the skills and knowledge required in the case management competencies framework.
So we can improve further in the care we provide for this group of people we need to build on and develop what has already been achieved between the NHS and social services. The NHS Improvement Plan: Putting People at the Heart of Public Services, (2004) set a new planned model for the management of long term conditions through self care, disease management and case management. The Department of Health (2005) document Self Care for people with Long Term Conditions shows how to support these patients including access to the expert patient programme.
Collaboration is made up of five levels, these are isolation, encounter, communication, collaboration by two agents and collaboration within and organisation. Effective case management requires collaboration between patients, carers and professionals (Gottlieb et al, 2006). Collaboration plays an integral part in providing a high standard of care and is crucial for the Single Assessment Process (SAP), coordination and planning of discharges to ensure there are successful care management systems in place across multidisciplinary teams i.e. NHS and social care (Sharkey, 2000).
Tschannen (2004) looked at collaboration and team work between healthcare professionals and believes that through collaboration there were more positive outcomes. This included patients generally feeling better and more solid care. There can be obstacles to overcome in collaborative working such as ‘personal’ obstacles where there is resistance to change or the lack of knowledge or skills, ‘professional’ where targets have to be met and ‘organisational’ where the right resources are not obtainable (Shaw et al, 2005). Integrating into current ways of working can be seen as a threat where ‘change’ or ‘new’ can mask the boundaries of sharing responsibility (Hudson, 2005).
Through using the Evercare model patients are identified by using decisive data from the hospital to show people aged 65 and over who have been admitted into hospital unplanned in the past year. Certain GP’s from certain surgery’s removed the patients if they we identified as not being at risk. From the data it showed that these patients made up 3% of the over 65’s and were 35% of all unplanned admissions.
There was also GP nominated patients added to the list through using another set of criteria, these people were thought by the GP to be at a high risk of being admitted into hospital (DH, 2005). District nurse can also access PARR tool (Patients at Risk of Re-admittance) to identify patients just like the community matrons but generally the district nurse identifies patients via the GP practice computer system by access information from the QUOF register, palliative care register or over 65 register. The district nurse team mainly get all there referrals from GP, hospital discharges, self referrals and the integrated network meeting were all disciplines such as district nurse, community matron, social worker, occupational therapist, intermediate care, physiotherapist, dietician and housing managers, attend a weekly meeting in there area to discuss patients. The district nurse and community matron take it in turn to be the key worker coordinating patient care at these meetings.
When the district nurse receives a referral they don’t just focus on that particular need they build a holistic view of the patient by obtaining a detailed assessment of patient needs. Due to the complexity of the Service Users conditions, the district nurse acts as a ‘detective’ to find the causes, or reasons why they are suffering from certain symptoms. This may be because of dietary, behavioural, lifestyle, habits, living conditions, medication, etc. a patients needs may change, there carers maybe unable to cope and changes in the level of support may lead to breakdowns in the ability to remain independent. This would lead the district nurse to liaise and integrate with other services.
Case management is VITAL due to the growing population of older people who suffer from long term conditions. Service and care provisions need to aim at prevention and the promotion of self-care which in turn will result in the improvement of health. Within case management there have been various model that have been tried but as stated by the Department of Health (2008), Our NHS, Our Future, there are different requirements in different places, and all have needs that are changing and these needs will be best solved by those who are local (DH, 2008).
District Nurses have a vast knowledge of the community they serve especially working within a home environment and will be able to provide care on all levels (Turner, 1998). Providing better care for patients with LTC’s is not just about treating their specific illness it is about providing individualised, responsive and holistic care in a full package within the patients lifestyle. As a District Nurse I agree with this statement, “our journey to achieve this has started, our challenge is to continue to take it forward and the evidence compels us to do this” (DH, 2008). Previously District Nurses have not been receptive to new ways of working even though they have the skill to use them in their daily work. The Department of Health and CDNA imply the District Nurse is perfectly placed for case management and carry out a key worker role as well as promoting patient care.
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