Clinical case management and its role in the continuum of care

1. Clinical case management and its role in the continuum of care

2. Introduction • Background to post • Elements of case management • Progress to date • How does it work in practice? • Conclusions

3. Background

4. Case management is • A strategy used to create a complete loop or network of services for a predefined population of patients. Case management cuts across formal hierarchies and services to produce a matrix of services

5. Clinical Case Management Clinical case management has at its heart a systematic approach to care The goals of case management is providing quality health care along a continuum, decreasing fragmentation of care across many settings, enhancing the client’s quality of life, and supporting value for money

6. Its about doing things differently? Bridging the gap – Integrated Care goes to the heart of quality of care for older people “ I expect person centred coordinated care”

7. The Continuum of Care

8. Elements of Case Management Level 3 – very high intensity users of unplanned hospital care. Level 2 – Complex single needs or multiple conditions Responsive specialist services, multi disciplinary teams & disease specific care pathways Level 1 – helping patients & carers develop the knowledge, skills & confidence to care for themselves and their condition effectively 4% 16-26% 70 – 80% long term illness

9. Important service-level design elements of care for older people with chronic and multiple conditions

10. Progressing that ICP – 2013-2015

11. Progress to date • 4 community based posts in Dublin North working in partnership with Consultant Geriatricians and many others • Development of enhanced ambulatory care pathways for older people to support admission avoidance including end of life • The role has facilitated real integration across traditional acute and community boundaries (development of community virtual ward )

12. ? What to do Options Discussed ? Acute Hospital ?Assessment at home MK doing well at home – 6 months later! ?Day Hospital ?OPD

13. Challenges Learn collaborative working Coordination of care Value placed on high touch Vs high tech care Working across organisational and funding silos – ICT support Measure our success

14. Conclusion • The success or otherwise of developments such as the clinical case manager relies on access to responsive management teams and services , clinical , technological and managerial supports • Clinical case mangers integrate and connect services around the client • The evidence to date speaks for itself!

15. Finally