Nick Goodwin introduces the key findings of our paper, Case management: What it is and how it can best be implemented, examining the benefits and barriers of this approach to care for people living with long-term conditions. He considers the practical implications of case management with examples from the United States, and sets it in the context of delivering an integrated care system in the NHS.
There is an emerging and coherent body of research that suggests that case managers should not just have good interpersonal skills, but should in addition have skills in health coaching or motivational interviewing.
Judy Hibbard has shown that tailoring the level of health coaching to the level of activation can support people with long term conditions on their 'journey of activation', such that they become confident daily decision makers and wise healthcare navigators.
It seems to me that 'case manager as coach' is the goal we should be aiming for- and perhaps we should be measuring patient activation as our proxy indicator of success.
Interested in other views
Emerging and consistent data is helping us to further understand the competencies we might expect of a case manager.
Specifically, one of their roles is to support people with long term conditions to make confident, autonomous daliy decisions about their health and to make wise decisions about accessing healthcare.
The skills we might expect of the case manager who is thus supporting people with long term conditions to become 'activated' also include motivational interviewing or health coaching skills.
Evidence from Judy Hibbard, in particular, shows that if we can tailor our support to the level of 'patient activation', we can support people to, in a sense, become their own case managers.
In order to do this, we need to use a set of indicators to ensure that our interventions are making a difference. We could use the 'Patient Activation Measure' or the 'LTC6'. The latter is a patient reported measure of clinical skills that support care planning. The LTC6 is being rolled out via John Oldham's LTCQIPP workstream.
Interested in other views
For Case management, this could mean re-assurance, mentoring/coaching (as Alf highlights), confidence building in the primary care (remember reading somewhere that 55% of what GPs do is to 'reassure'). Link this to Reablement in social care, which mostly follows the same ethos.
The underlying message - as ever - is that we need to start seeing the patients, services users as equals and start doing things 'with' them. The success of Amazon, E-bay, Facebook etc is because of this personalised engagement/delivery system that focuses on the Customer and makes them, as much as possible, accountable to the decisions they make (or supported to make). There is no sense of: 'This is my entitlement and you get it right and if you get it wrong, it is your mistake and you have played with my life'.
Plus, by removing aspects, as far as possible, which do not create any 'value' to patients or staff, we can produce better outcomes for sure at comparatively less resource use (as highlighted in various initiatives across the developing world where high productivity and high volume is achieved at comparatively low cost - of course this is not a like for like comparison but the lack of complex structures (as in NHS) - have created better possibilities for innovation and creativity
And let me be clear, such efficiencies are comparatively easier in private, social enterprises than Public Sector but it is certainly achievable in public sector with focused long term reforms.
Another distortion (?) of the case management ethos we suffer is the idea that the 20% of the patients using up 80% of acute beds are synonymous with those that can self-manage-hence we are asked to target this 'high risk' group in the hope that we can prevent them being admitted to hospital.Another major problem we face is that no matter how many admissions we avoid; the next most ill person will be admitted by junior hospital doctors so that overall no reduction in acute admissions is seen.Not sure about other areas but in my area it seems that no Trust, PCT or politician wants to be seen closing hospital beds in any shape or form.