The evidence for a targeted, nurse-led approach to care is mixed but it would be wrong to view this as a flawed concept. Case management still has a central part to play in meeting the needs of older people and those with complex illnesses
The reforms included in the Health and Social Care Bill have been hotly debated. One result of this process is a renewed policy emphasis on ‘integrated care’ that will seek to better co-ordinate services around the needs of the individual.
At a recent conference at the King’s Fund, Paul Burstow, the minister for care services, argued that ‘the case for integrated care is clear cut … it reduces costs and improves the quality of services’. He then challenged health and social care commissioners to work more closely together to support the development of such services.
Case management has become a widely accepted approach internationally to caring for people with complex chronic illnesses, and it is a key strand of the Department of Health’s model for caring for people with long-term conditions. It can best be described as a targeted, nurse-led approach to care that involves case finding, assessment, care planning, and care co-ordination.
The premise of the model is that proactive, community-based care is more cost-effective than downstream acute care – particularly if it is targeted at those individuals with the greatest risk of an emergency admission. In other words, its key aims represent the ‘holy grail’ of system reform: improving the care experiences and care outcomes of patients while reducing expensive hospital utilisation (principally in terms of emergency admission, but also lengths of stay).
The evidence for the impact of case management, however, is mixed. In particular, anecdotal evidence from clinical commissioning groups is that they are beginning to turn their backs on investing in nurse-led case management since it does not appear to be having any significant impact on reducing emergency admissions and that, regardless of patient experiences, it represents an additional expense rather than a solution to financial imperatives.
However, it would be very wrong to conclude that case management is a flawed concept. There is ample evidence from around the world to suggest that the approach can work. Systematic reviews of the evidence, for example, show that case management might not reduce emergency admissions but can have significant impact in other ways – for example, in improving hospital discharge, reducing re-admission rates, and lengths of stay.
Other work has shown that the need for primary care-based consultations or access to specialist nurses in the community reduces as individuals become more empowered to manage their own care. Nonetheless, it is clear that many case management programmes have not been as successful as they could have been.
The key issue appears to be that case management has not often been planned and designed as an intervention thoroughly enough – for example, in ensuring that it is led by appropriately and professionally trained case managers and teams.
Common problems have included a failure in care continuity since no-one, or no team, takes assigned accountability for the services individuals receive, exacerbated by caseloads that are too large to manage. Care planning can also become too much of a technocratic exercises to the benefits of professionals as opposed to a way of engaging patients and their families in making choices about care and treatment options.
More fundamentally, those selected for intensive case management may not actually need or benefit from it – the ability to target the right people is probably the most problematic, but also most important, prerequisite for success.
Case management also needs to be viewed through the lens of wider system reconfiguration. It clearly will never work if there is not also good access to an extended range of primary care services or community-based packages of social care that enable rehabilitation and re-ablement. Case management clearly has a central part to play in meeting the growing needs of older people and those with complex and chronic illnesses, but it needs careful application if the benefits are to be realised
Nick Goodwin is senior fellow at the King’s Fund and is co-author of the new report Case management: What it is and how it can best be implemented
