COMPLEX CASE COMPLEX CASE MANAGEMENTMANAGEMENT

Jonathan Webster

Consultant Nurse, Older People

Local Opportunities(summary)

• Reduction in admissions to secondary care – proactive case management

• Whole systems planning and commissioning• Recognising & valuing prexisting services• Workforce development – education & training• New ways of working• Opportunity to develop new roles within integrated

teams – complex case management• Expert patient programme

HVOP PN DN NP

Chronic Case Management Care Management Case Management for

Population High Risk Patients High Complex Needs

Level 1 Level 2 Level 3Health Promotion

Role of the Primary Care Practitioner/ Nurse Practitioner for Older People

(Summary)

• Focus on a target population within a geographic locality

• Skilled in undertaking a comprehensive history leading to the instigation of therapeutic treatments in order to improve health outcomes

• Through joint working with primary care ascertain diagnosis and treatment plans with timely follow-ups as part of caseload management

• Using advanced skills and expert knowledge identify subtle changes in the person’s condition

• Discuss early signs of ill health

• Working in partnership with GP’s and the Community Nursing Team in developing active therapeutic care plans

• Manage a case load based on chronic disease management

• Lead the development, implementation and evaluation of protocols, policies and integrated care pathways

‘Chronic disease represents a significant and exciting challenge for the NHS. Good chronic disease management offers real opportunities for improvements in patient care and service quality and a reduction in costs.’

Department of Health 2004