This chapter is concerned with the integration of care at the individual level, where services are co-ordinated in response to the assessed needs of an older person and their carer. It describes different models of case management, with lessons from research, and provides key steps in introducing case management, including the skills and knowledge base of staff taking on the role of case manager.
The processes of case management, as ways of achieving more integrated and co-ordinated services, have been defined and re-defined over a number of years. The terms ‘care management’ and ‘case management’ have often been used interchangeably, so for consistency, the term ‘case management’ is used throughout this chapter.
There is no universally accepted definition – particularly where there has been concern that the term ‘case’ is derogatory – but there is some consensus about the main components of case management (Hudson 1993). These are:
Challis (1999) describes case management itself as:
Source: Department of Health (1991)
* Stages 1 and 2 are included in some models, such as this one.
Co-ordinating services or care packages in response to the assessed needs of older people and their carers is a core part of delivering integrated, person-centred care. Good, comprehensive assessment and care planning – undertaken in a way that properly engages with the older person and their carer, and involves them in decisions about their care plan – is crucial in ensuring that the most appropriate services are provided.
Co-ordinating these processes and services can avoid unnecessary duplication and promote good continuity of care. This promotes older people’s independence by preventing a deterioration in their health and home situation, and by managing crises, as Challis describes: ‘The impact of services upon well-being is much greater when those services are planned and co-ordinated in an integrated fashion’ (Challis et al 2002).
So the aim of case management is to tailor services to the individual older person in order to improve the quality of their life, taking into account the wishes and needs of their carer – be they a partner, relative or friend.
Organisations will be considering the potential of case management to offer a cost-effective and efficient way of co-ordinating services so that older people receive:
The challenge for case management is that it takes place at the level of service provision at which needs and resources, scarcity and choice have to be balanced. ‘Care management is no panacea but rather a mechanism which, if effectively implemented, can offer one way to manage the tension between social objectives and economic constraints in long-term care services’ (Challis 2003).
In this model, case managers co-ordinate services for older people with severe and complex needs, undertaking all of the functions described in Fig 7 opposite, aiming to tailor services to the needs of individuals across time and place of service utilisation. These case managers may be employed by a single agency (either a provider or purchasing organisation) or by inter-agency arrangements, with or without a budget to commission or co-ordinate services.
In Castlefields Health Centre, Runcorn, case managers for older people are based in a general practice targeting specific groups of older people who are at high risk of hospital admission or making heavy use of services. The case managers undertake an individual needs assessment, working with the older person to:
Another aspect of the integrated service is close working between a practice-based social worker and a nominated district nurse. Results indicate:
Source: Carrier (2002)
In Finland, case managers have been used to eliminate hospital discharge problems and have worked with specific groups of older people to organise services and treatment in hospital before discharge as well as co-ordinating services in people’s own homes for a fixed period of time.
Source: Ala-Nikkola and Valokivi (1997)
A study in Finland shows that where nurse case managers worked with older people with dementia, the older people’s placement in long-term residential care was deferred – particularly for those patients with complex and severe problems. This intervention also had long-term effects on caregivers, and helped them to return to a normal life.
Findings also indicate that the nurse case manager must work in close collaboration not only with the social and health care system, but also with a physician, such as a general practitioner, who knows the patient. The nurse case manager requires problem-solving abilities, initiative and a high capacity for responsible and independent work.
Source: Eloniemi-Sulkava (2002)
In this model, there are organisational procedures in place to make sure that discrete tasks of assessment, individual care planning and regular reviews are carried out for older people. In other words, these tasks may be carried out by more than one person.
In England in the early 1990s, some local authorities with responsibility for social services focused on the discrete stages of case management when implementing case management arrangements. In 1994, a study showed a trend towards an administrative form of case management characterised by a lack of continuity of staff involvement in the tasks of case management. It was becoming a process that was applied to all service users rather than being targeted on more complex cases.
Commentators suggest that it is important to discriminate between ‘intensive case management’ (where there are designated care managers for those with complex needs) and more effective organisational procedures where core tasks of assessment, care planning and regular reviews are effectively carried out for all service users.
Source: Challis (1999)
Here, case management is supported by a multi-disciplinary team, with workers drawn from different agencies. One of the team acts as a case manager or keyworker.
In two regions of Belgium, services practise a clinical nursing case management model for geriatric patients and their families. Each patient and family carer is provided with an individual package of care, designed and implemented in a multi-disciplinary context. The aims are:
In this model, case management focuses on achieving clinical outcomes, and fiscal management plays no role – or a limited one. The services delivered for each individual are based on their individual assessment. A comprehensive array of services is co-ordinated, and the family is offered support and education, as well as skills training and medication and symptom management. Services are provided through a multi-disciplinary team, which includes the case manager, nurses, physicians and social workers. Collaboration with psychiatrists, other physicians and hospitals is also an important component of this clinical case management model (see Tombeur 2002).
Source: Borgermans et al (1998)
In this model, case managers are employed by an independent agency in a way that is similar to service brokerage. Here, case managers can be powerful advocates but may have weaker leverage within the service systems. They may primarily provide advice and information.
In central Finland, a local caregiver association has employed a worker to tailor support for families, particularly for the time at which caregiving begins, or when changes take place in the family situation. This has included working with the carer and the older person being supported, to identify their needs, provide information and help them access suitable services. Network or case meetings have been organised between the carers, older person and service providers to establish suitable care packages. Carer group meetings have also been set up, and are felt to provide valuable peer support.
Source: Mornings Project Caregiver Association, Jyvasseudun Omaishoitajatry. Email: eija.luomaa@omaishoitajat.inet.fi
This is not strictly a ‘model’ but it has been included because it offers control by older people. It involves introducing some form of direct payment or personal care budget as an alternative to service provision being arranged by another body. It offers the option for older people (or their carers) to be their own ‘care co-ordinators’ and to buy in services that meet their needs.
In the Netherlands, since 2003, older people who are entitled to home care can ask for a cash payment rather than care in kind. ‘Advisers of older people’ are available to help them with the administration and provide information about the supply system so the older people can arrange their own care packages. These advisers, some of whom are older volunteers, aim to empower older people to keep their autonomy by providing information, advice and assistance for those older people preferring to self-manage.
Source: van Dam and Begemann (2004)
Here, a case management agency (of the type often used in social insurance schemes) contracts the services included in the client’s care plan. The agency will control costs by selectively contracting with providers.
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Model
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Advantages
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Disadvantages
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|---|---|---|
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Intensive care management
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Holistic approach to needs. Targeted at people with complex needs |
Success is dependent on strength of inter-agency, inter-professional arrangements. Single agency models may restrict access to wider services and resources
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Shared core tasks model
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Allows for key tasks of care management – assessment, care planning and review – to be built into organisational procedures for large number of service users with less severe needs
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Lack of continuity of staff for individual service users and less appropriate for older people with complex needs
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Joint agency model/key worker model
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Good access to multi-disciplinary services
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Nominated key worker may have difficulty balancing that role with their own professional input or service delivery
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Independent brokerage model
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Strong advocates for older person and carers
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Likely to lack influence in service system
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Older person or carer co-ordinates care using direct payments
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Older person able to control and choose own package of services
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Support may be needed for older people who prefer to self-manage
|
Disease management, chronic illness management and integrated care pathways are other models of managing care, which seek to improve the co-ordination of services and clinical interventions. These models are based on anticipated clinical practice for a client group that shares a particular diagnosis or set of problems. The models provide a multi-disciplinary template of the plan of care, based on guidelines and evidence. These forms of managed care are primarily about promoting consistency in care for one particular health problem or chronic disease.
In some countries, case managers are employed to work with people with chronic disease to improve patient education and self-management, and to liaise between primary and secondary health professionals. However, many older people have multiple health problems with a range of inter-related needs that require integrated services beyond the health system.
Evaluation of different models of case management has highlighted the following points:
Implementing a case management model involves a series of activities. These can be broken down into the following steps:
To plan the introduction of a case management system, it is important to agree:
For example, if a joint agency model is chosen, discussions between health and social care agencies may consider:
Agreement will be needed about the potential for pooling or aligning budgets from the two agencies, the level of devolved budgetary responsibility and the system of accountability.
The roles and responsibilities of the case manager will need to be clarified, including those relating to assessment. This will include clarifying who takes on the different tasks of the case management process and whether the case manager is a distinct and separate role or whether this will be in addition to a professional role.
There will also need to be agreement about the appropriate size of caseload for the case manager, allowing time to plan individual care packages and programmes, establish rapport with user and carer and undertake reviews. There is evidence of a decreasing capacity to perform follow-up, monitoring and review as caseload size increases (Challis 2003).
As a priority, it is important to ensure the older person and their carer are at the centre of this new process, by, for example:
All other organisations involved in the service system that will be in contact with, or affected by, the new case management process need to be involved in discussions to clarify how this will relate to their work and services. This will include agreeing shared protocols and procedures – for example, in making and accepting referrals, confidentiality over information sharing and managing emergencies.
Good information systems are essential to support the case management process. They must be able to:
Staff from a range of professional backgrounds may be suited to taking on the role of case manager but will need the following skills and knowledge base:
Other staff in the service system will need to know about the role and responsibilities of case managers, so good communication and trust need to be developed between different professionals and the case manager. Any fears about losing responsibilities must also be addressed.
At an individual level:
At system level, the first task is to set up monitoring systems and joint evaluation processes across agencies to answer:
The second task is to make sure any unmet needs are being systematically collated and fed into planning and decision-making bodies.
The first potential barrier is the danger of a case manager being more heavily influenced by their employing organisation than by the preferences of older people – particularly where case managers are part of the services that need to be co-ordinated, or where case management is seen primarily as a form of budgetary control and a way of restricting access to the service system.
A further barrier is that case management, with its overhead costs of the case manager, may tend to increase costs for those with less severe needs. Difficulties can also arise where service boundaries are not co-terminous, and case managers have little influence in wider networks.
Finally, limitations can arise if staff acting as case managers are unable to think outside of their usual professional role and do not think about holistic needs and flexible, imaginative, co-ordinated service solutions.
The success of any model of case management depends on local and national factors that ensure the provision of sufficient appropriate services to co-ordinate, as well as organisational and professional support for those undertaking the role of case manager. These factors include:
These factors are addressed in full below.
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Van Dam S, Begemann C (2004, forthcoming). ‘Advice and counselling for the elderly – ministering angels in disguise’, in European Challenges and Local Realities – Initiatives in care and welfare in the Netherlands. Utrecht: Netherlands Institute for Care and Welfare (NIZW).
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