One in three of us have a long term condition; that’s around 15 million people in England. Patients with long term conditions use seven out of every ten inpatient bed days and over half of GP appointments. Supporting these patients effectively and thus reducing the impact they have on local health and social services has been a key driver for our work in Northamptonshire. For the last three years we have been running a case management model, Pro Active Care (or PAC). Through PAC we have significantly reduced the emergency admission growth rate in patients with long term conditions (0.7% admission growth rate in those practices undertaking PAC, compared to 4.5% growth rate in our comparator PCT sites).
PAC now involves more than 55 of our 70 GP practices and covers a population of over 600,000 people,
Our clinicians work closely with their patients and their carers to create innovative services that better support people at home. So what are our ten top tips for making case management a success?
1) Involve all the practice and community services teams in case management – LTC management should be a contractual arrangement.
2) Identify those patients who are at greatest risk of emergency admissions and readmission, using a range of information, such as risk stratification tools, frequent A&E attendance data, practice intelligence, out of hours’ attendance and ambulance frequent caller data.
3) Set up weekly practice meetings involving community nurses, GPs and other members of the primary care team to case discuss, develop pre-emptive care plans, and provide timely interventions. These will include increased community nursing support, medication reviews and social care involvement.
4) Include patients who are at the end of life in case management. We have found that over 60% of patients in PAC who are dying are able to do so in places of their preference, by and large at home. This is particularly important for those patients who do not have malignant disease, and who are more likely to be admitted into hospital at the end of their life.
5) Work with acute service colleagues to identify patients suitable for PAC and make sure they are able to directly refer the patient into PAC via the practice teams
6) Work with social care colleagues so that they too can directly refer the patient into PAC
7) Enlist support from the third sector so that patients can have social needs met, this will include carers organisations so that the needs of carers are not forgotten.
8) Make sure that there are good interfaces with all services that support patients with LTC’s. This will include Integrated Care teams, Mental Health teams and specialist services, such as diabetes heart failure, and Palliative Care services.
9) Develop a reporting system for practices and community services to account for their activity associated with case management
10) Provide monthly feedback to practice and community teams on the progress made in reducing their emergency admission rates.
LTC management is not a quick fix, something that is done once and then forgotten, but is an ongoing responsibility for all involved. It is everyone’s business and requires a whole system approach, which means that organisational barriers must be dismantled so that professionals are able to maximise their commitment to work collectively to improve health outcomes and quality of life for their patients.
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