Case Management – long term conditions

1. Case Management – long term conditions Liz Thwaite ANP Craven Collaborative Care Team

2. Aims of session • To develop an understanding of Case Management • Using the case of Fred and Norma to illustrate how to case manage proactively. • Demonstrate how good case management reduces avoidable emergency admissions. • What constitutes good case management.

3. Over 15 million people in the UK are living with a long term condition and currently in excess of 70% of the Health & Social Care budget is spent treating these conditions.

7. Services that are or could be involved at any stage. • Community Matron • District Nurse • Optician • Occupational Therapist • Nurse Specialists • Voluntary agencies • Age uk • Secondary care consultants. • Community Geriatrician • Carers resource • Pensions agency • Community Mental Health team • Podiatrist • Pharmacist – local chemist • General Practitioner • Telehealth • Dietician • Physiotherapist • Palliative care team • Intermediate care team • Step up beds • Practice nurse • Carers – formal and informal • Social services • Community Equipment store • Day care/respite • Handiman scheme – key safe • Careline • SALT

8. Fred and Norma

9. Freds Progress. • Fred remains alert and orientated. He is eating and drinking. • He is breathless on exertion. • His NEWS has increased from an aggregate of 3 to 5. • The intermediate care team contact you for advice. • What further information do you need? • What action are you going to take?

10. Fred has recovered • He is discharged from intermediate care team, social services enabling team are now taking over. • What on going support will Fred need?

11. And finally Norma • What has come to light since we have been caring for Fred? • What can we do to support Norma? • What follow up support might Norma need. • What support will Fred need in future in his role as carer for Norma.

12. Key points to remember • Communication – timely, pick up the phone, send a task, fax the consultation, bleep us. • Integration with and use of wider multidisciplinary team, including good links with secondary care specialists. • The GP is a vital part of the case management process – it will not succeed without your support.