Published: 08/12/2005 Volume 115 No. 5985 Page 32 33
As more community matrons come into post, case management comes under greater scrutiny to prove that these relatively new members of the healthcare professional workforce are delivering improved outcomes.
Advocates can point to a body of evidence demonstrating better clinical quality and higher patient satisfaction. However, given the current financial position of the NHS and looming targets, managers want to see investment in the new service show a return in reduced hospital use.
This is particularly challenging because research findings on cost reduction have been variable, with good results in less than half of studies.
Similarly, pilot work has had mixed outcomes, with some models lowering hospital admissions, beddays and even GP workload while others have been less convincing.
The key to local service development is replicating the success stories.
Some of the research should be approached with caution. Case management has been treated as a catch-all term encompassing a variety of approaches and interventions, impeding clarity over terminology and operating boundaries.
It is also a systems approach and a complex intervention involving patients, care givers and the entire health and social care network.
Researchers are faced with multiple interactions in the community matron role that make it difficult to isolate cause and effect.
But it is possible to identify a number of the key building blocks.
The foundation is a workforce with the right expertise. Although the NHS has an excellent skills base, training is needed in evidence-based practice in case management of long-term conditions - these generate most unplanned hospital admissions. In this respect, the NHS now has a good start with the community matron competence framework.
A second critical success factor is effective targeting, identifying the high-risk population group in the top segment of the Kaiser Permanente 'triangle'.
This group constitutes about 5 per cent of people aged over 65 and 1 per cent of the working-age population - but it costs the health system three or more times the average for this age group.
About 40 per cent can be identified by a predictive model that groups individuals into risk categories on the basis of diagnostic and past use data.
Numerous models of this type are in use in the US, and now in the NHS.
However, because community matrons fill most of their caseloads through direct referrals from the local health and social care network, it is crucial that the qualifying criteria are clearly agreed by all local stakeholders.
This high-risk population has varying needs. The key is a model of clinical intervention that addresses the diversity of the group.
Case management is proactive and most patients will be offered the service during a relatively healthy phase of their condition cycle. The aim is to empower patients to take more control over their conditions and prevent exacerbations and crises.
At first, the patient may not need the service, but once engaged they must become an active collaborator.
It is important for the community matron to design a care plan around the patient's goals and expectations of outcome, and that the plan and assessment on which it is based is holistic and spans all the needs of each individual.
This model will allow patients to move down the long-term conditions triangle into supported selfmanagement. Patients can be discharged, creating further capacity and optimising productivity.
To implement the plan, community matrons co-ordinate a number of key services. Partnershipworking with primary care is a cornerstone. The GP retains the role of lead clinical manager and collaborates with the community matron by making practice resources available to any member of the primary care team.
The community matron consults the GP on selecting patients, agreeing the care plan and monitoring effectiveness. The GP delegates authority to make referrals. There will be some investment of time by GPs in the early phases of any new project but, within six months, they can see payback in terms of reduced workload.
The second most important link service is social care because about 50 per cent of patients will need a new or revised package.
Clear protocols and fast-tracking access systems are needed for a rapid turn-around between referral and implementation. Those working across the health and social care network must recognise that proactive care for high-risk patients is as much a priority as reactive care is for acutely ill patients.
Similar access criteria should be agreed for NHS intermediate care and other remedial therapy services.
A comprehensive directory of voluntary services will be invaluable.
Any cost implications for services should be carefully monitored, although they need not escalate. For example, case management can improve the functioning of some patients on intense social care packages. As this improves, the package and associated cost can be reduced.
Development and access to specialist knowledge through a network of informal mentors will ensure referrals are appropriate and help community matrons develop confidence in risk management.
This network should comprise GPs with a special interest, a linked social worker, a mental health worker specialising in older people and, if available, a community geriatrician.
From an operational perspective it is important that community matrons allocate sufficient dedicated time to the role.
Combining it with too many other functions, especially hands-on care of acutely ill patients, often leads to pro-active care falling down the list of priorities and diluting the impact.
The service can also be compromised if the caseload is too large or becomes clogged with inappropriate cases that are not among the top 5 per cent of the key target group.
Patients with long-term conditions move up and down the triangle and many of next year's high-cost patients will be drawn from this year's less dependent ones, so a concentration on the current most unwell and highest-cost cases may prove counter-productive.
Also, a practitioner should not retain patients who are not progressing on the caseload. Regular peer-review meetings can provide a useful forum for these issues.
Finally, an effective case-management programme requires good information flows and practical support systems.
If a managed patient is admitted to hospital and the community matron immediately alerted, earlier discharge can be facilitated and there is firm evidence of consequent reduction in bed-days - a key target.
Community matrons should be given a central role in performance monitoring. A minimum data set needs to be agreed at local level and the staff given user-friendly tools to capture it on a patient-by-patient basis as well as monitoring and reporting in aggregate.
The information generated from effective practice reinforces job satisfaction and provides powerful evidence to the wider health and social care network that community matrons can prove their worth. .
David Cochrane is director of Conrane Consulting and Susan Fitzpatrick is deputy director of Tanaka Business School Centre for Health Management at Imperial College London.