Making the case for case management

Over the next decade and beyond, broad shifts in demographic and disease status will mean that patients with complex long-term chronic illnesses will increasingly absorb by far the largest share of health and social care budgets. In order to meet this challenge, the health and social care system needs to redesign the way it delivers care through a better co-ordinated and integrated set of services around the needs of individual patients and service users. Case management has become widely accepted internationally as a key approach that might help achieve this. Case management 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 are to improve care experiences and outcomes whilst reducing expensive hospital utilisation (principally in terms of emergency admissions). The evidence for the impact of case management, however, is mixed. In particular, many nurse-led case management schemes – while improving the way users experience care – have not appeared to make inroads into significantly reducing emergency admissions and costs. Hence, it has come to represent an additional expense on the system rather than a solution to financial imperatives, or an unnecessary duplication of the role of the general practitioner. However, case management is not a flawed concept. There is ample evidence to suggest that the approach can work even if it is also 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 often been badly planned and designed as an intervention. Common problems have included a failure of case managers, or their teams, to take assigned accountability for the services individuals receive – consequently the care experiences of many patients can deteriorate as they become confused about how their care is managed. 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 reablement. A big failing in approaches to case management has been the lack of ability to provide care out-of-hours or the inability of the case manager to arrange access to a range of local services. Most unnecessary emergency admissions in case management schemes happen due to these two factors. Case management clearly has a central part to play in meeting the growing needs of older people and those with complex chronic illnesses, but it needs careful application if the benefits are to be realised. At a policy level there needs to be a fundamental rethink of current incentives within the health system that serve to reinforce investment and expenditure in acute hospitals rather than tackling the root cause of the issue, beginning with the at-risk individual living at home. Nick Goodwin is a 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 This article is published by Guardian Professional. Join the healthcare network to receive regular emails and exclusive offers.