Clinical case management and its role in the continuum of care
Introduction
• Background to post
• Elements of case management
• Progress to date
• How does it work in practice?
• Conclusions
Background
Case management is
• A strategy used to create a complete loop or network of services for a
predefined population of patients. Case management cuts across
formal hierarchies and services to produce a matrix of services
Clinical Case Management
• Clinical case management has at its heart a systematic approach to
care
• The goals of case management is providing quality health care
along a continuum, decreasing fragmentation of care across many
settings, enhancing the client’s quality of life, and supporting value
for money
Its about doing things differently?
Bridging the gap – Integrated
Care goes to the heart of quality
of care for older people
“ I expect person centred
coordinated care”
The Continuum of Care
Primary
Care
Older Persons
Client
Community
Acute
Hospital
&
Community
Interface
Rehab
Elements of Case Management
4
%
Level 3 – very high intensity users of unplanned
hospital care.
Level 2 – Complex single needs or multiple
conditions
Responsive specialist services,
multi disciplinary teams &
disease specific care
pathways
Level 1 – helping patients & carers
develop the knowledge,
skills & confidence to
care for themselves and
their condition effectively
Important service-level design elements of care for older people with
chronic and multiple conditions
Comprehensive
Assessment
Care Planning
Single Point of
Entry
Care Coordination
Progressing that ICP – 2013-2015
CommunityFacing
Geriatrician
Old Age
Psychaitry
Acute Care
Access
Older
Person
Respite/
Assessment
and
Rehabilitation
Bed Access
Clinical Case
Manager for
older persons
( 2013)
Home Care
and
Community
Intervention
Team
Day HospitalRapid Access
Progress to date
• 4 community based posts in Dublin North working in partnership with
Consultant Geriatricians and many others
• Development of enhanced ambulatory care pathways for older people to
support admission avoidance including end of life
• The role has facilitated real integration across traditional acute and
community boundaries (development of community virtual ward )
?
What
to do
Phone call from GP to
case manager
CGA at home with case
manager next morning
• 90 yo F, frail, recent
discharge acute
hospital, multiple
co-morbidities, not
doing well at home,
not eating, not
drinking, carer
stress++
? Acute
Hospital
• Decision to remain at home
with supports
• Home care package
• Community Intervention Team
• Care Plan
• Full Clinical review
• Anticipatory care
Plan
• Respite options
• Plan for
monitoring and
follow up
?Assessment at
home
Options
Discussed
?OPD
Interface Geriatrician
?Day
Hospital
MK doing well at home –
6 months later!
Challenges
• Learn collaborative working
• Coordination of care
• Value placed on high touch Vs high tech care
• Working across organisational and funding silos – ICT support
• Measure our success
Conclusion
• The success or otherwise of developments such as the clinical case manager
relies on access to responsive management teams and services , clinical ,
technological and managerial supports
• Clinical case mangers integrate and connect services around the client
• The evidence to date speaks for itself!
Finally