Transcript Integrating Care Through Clinical Case Management

INTEGRATING CARE
THROUGH CLINICAL CASE
MANAGEMENT
Nicky Hughes Lead for
Chronic Conditions
Management
AIM OF PRESENTATION
• provide a background into the chronic conditions agenda
• discuss the Clinical Case Management model
• consider the evaluation to date
• The patients experience
• Service user feedback
CHRONIC CONDITIONS
MANAGEMENT
From fragmentation to integration
Care
Pathways
Expert
Patient
Specialised
CDM
Services
Unified
Assessment
Integrated CCM
Model
CLINICAL CASE MANAGEMENT
Background
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•
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•
Evercare model
Community Matron model in England
Swansea evaluation
Mid Staffordshire review
Clinical Case Managers
The Clinical Case Managers aim to:
• Help individuals with complex chronic conditions to self
manage their conditions and remain healthier for longer
• To avoid admission or reduce length of stay should
admission be unavoidable
• To provide support for individuals in their own homes
• To optimise independence for individuals and their
carers and enhance their quality of life
• To proactively manage patient problems and engage
with other professionals and statutory or voluntary
organisations to resolve them.
EVALUATION
Evaluation
• Admissions by pilot GP sites by HRG per week
compared to previous year and other non pilot
GP’s
• Bed days used by pilot GP sites by HRG per
week compared to previous year and other non
pilot GP’s
• Patient experience (Random Sample = 145) 6
months prior / post intervention
• Patient / carer stories
• Primary care team questionnaire
Clinical Case Manager GP’s bed days
used by HRG’s relating to CCM per
week
CCM GP bed days used
250
200
150
100
UCL=77.699
CEN=55.375
UCL=48.573
50
LCL=33.051
CEN=31.686
LCL=14.799
9
9
06
20
0
8
03
20
0
8
52
20
0
8
49
20
0
8
46
20
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8
43
20
0
8
40
20
0
8
37
20
0
8
34
20
0
8
31
20
0
8
28
20
0
8
25
20
0
8
22
20
0
8
18
20
0
8
16
20
0
8
13
20
0
8
10
20
0
8
07
20
0
8
04
20
0
7
01
20
0
7
50
20
0
7
47
20
0
7
44
20
0
7
41
20
0
7
38
20
0
7
35
20
0
7
32
20
0
7
29
20
0
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26
20
0
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23
20
0
7
20
0
20
20
0
17
14
20
0
7
0
Clinical Case Managers commenced April – June 2008
Bed days saved
• 29 bed days less per week per 100,000 head of
population for the pilot practices compared to
the others
• Cost saving per 100,000 head of population of
£381,012 per annum (£250 bed day)
• Cost of pilot service £200,000 per annum
• Saving of 59 beds
CCM caseload conditions on GP register
Chronic conditions on GP register
120
100
CV
A
/T
IA
D
CH
s
Ar
th
rit
i
PD
30
10
18
4
4
13
3
de
pr
es
sio
n
Sc
iz
op
hr
en
ia
19
De
m
en
tia
21
a
34 33 31
20
0
CO
Chronic conditions on GP
register
51
As
th
m
80
60
40
97
2
Risk stratification
5%
27%
20%
0 conditions
1 condition
2 conditions
3 conditions
4 or more
22%
26%
Age profile
35
31
30
26
26
25
25
20
16
15
9
10
5
Series1
1
1
0
0
1
4
5
0
36-40 41-45 46-50 51-55 56-60 61-65 66-70 71-75 76-80 81-85 86-90 91-95
96100
Services used by patients seen by the Clinical Case
management team for 6 months pre intervention
and 6 months post
6 months Pre and Post Clinical Case Manager intervention service
use
400
350
347
345
242
241
250
200
299
288
300
Pre intervention
163
159
post intervention
150
100
103
74
57 54
36
50
16
O
PD
at
te
nd
s
A&
E
Ad
m
iss
io
ns
O
H
G
P
O
its
vis
e
ho
m
G
P
te
le
ph
on
e
G
P
G
P
at
te
nd
s
0
Patient stories (themes)
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•
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•
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Quicker access to help
Help with medications
Link between services
Information
Support and comfort
Confidence in the nurse to deal with
condition
Quotes
• ‘ Before the CCM I was constantly in and out of
hospital all the time, now it is wonderful’
• ‘ I feel uncomfortable bothering the GP and
would not call even if I felt unwell – very
comfortable to ring CCM’
• ‘She works in the background sorting out
problems that other care workers are not able to’
GP questionnaire (themes)
• Link between patient and the GP
• Increased compliance with medications
• Big improvement in the management of all
round needs of patients with chronic illness
• Vast Clinical Knowledge / confident in ability
• Regular review and timely interventions
• Valuable member of the team
GP Quotes
• ‘Initially our practice was a little sceptical
about the role and whether it would further
our workload. This has not been the case,
in fact, the workload has decreased’
• ‘ A very good service and another piece of
the jigsaw of primary care’
Out Patient Eye
Clinic Community
Pharmacy
District Nurses
GP
Acute Response
team
Ambulance
Care and repair
A&E
Home Care
Package
Clinical Case
Manager
Memory clinic
Age concern
Telecare
Community alarm
Family
The way forward
• Increase the numbers of Clinical Case
managers
• Base case loads on the risk of hospital
admission score
• Develop the community nursing team to
integrate the model across core services
Over to the users
ANY QUESTIONS?