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Case management for long-term conditions: implementation and processes

Published online by Cambridge University Press:  24 September 2009

SIOBHAN REILLY ,
JANE HUGHES  and
DAVID CHALLIS
SIOBHAN REILLY*
Affiliation:
National Institute for Health Research School for Primary Care Research, University of Manchester, Manchester, UK.
JANE HUGHES
Affiliation:
Personal Social Services Research Unit, University of Manchester, Manchester, UK.
DAVID CHALLIS
Affiliation:
Personal Social Services Research Unit, University of Manchester, Manchester, UK.
*
Address for correspondence: Siobhan Reilly, NIHR School for Primary Care Research, National Primary Care Research and Development Centre, Williamson Building, University of Manchester, Oxford Road, Manchester M13 9PL, UK. E-mail: siobhan.reilly@manchester.ac.uk
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Abstract

This paper presents a structured literature review that focused on comprehensive case management by nurses for adults with long-term conditions living in the community. The emphases of the review are the implementation of case-management approaches, including its roles, core tasks and components, and the coverage and quality of the reported implementation data. Twenty-nine studies were included: the majority were concerned with case management for frail older people, and others focused on people with multiple chronic diseases, high-cost patients, or those at high risk of hospital admissions. All the studies reported that case managers undertook the core tasks of assessment, care planning and the implementation of the care plan, but there was more variation in who carried out case finding, monitoring, review and case closure. Few studies provided adequate implementation information. On the basis of the reviewed evidence, three issues were identified as key to the coherent and sustainable implementation of case management for people with long-term conditions: fidelity to the core elements of case management; size of caseload; and case-management practice, incorporating matters relating to the continuity of care, the intensity and breadth of involvement, and control over resources. It is recommended that future evaluations of case-management interventions include a comprehensive process component or, at the very least, that interventions should be more fully described.

Keywords

nurse case managementlong-term conditioncommunity careimplementationliterature review
Type
Articles
Information
Ageing & Society , Volume 30 , Issue 1 , January 2010 , pp. 125 - 155
Copyright
Copyright © Cambridge University Press 2009

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References

Aadalen, S. P. 1998. Methodological challenges to prospective study of an innovation: interregional nursing care management of cardiovascular patients. Journal of Evaluation in Clinical Practice, 4, 3, 197–223.CrossRefGoogle ScholarPubMed
Allen, S. 1999. Description and outcomes of a Medicare case management program by nurses. Home Health Care Services Quarterly, 18, 2, 43–69.CrossRefGoogle ScholarPubMed
Applebaum, R. and Austin, C. 1990. Long Term Care Case Management: Design and Evaluation. Springer, New York.Google Scholar
Arai, L., Roen, K., Roberts, H. and Popay, J. 2005. It might work in Oklahoma but will it work in Oakhampton? Context and implementation in the effectiveness literature on domestic smoke detectors. Injury Prevention, 11, 3, 148–51.CrossRefGoogle ScholarPubMed
Arnold, D. 1987. The brokerage model of long term care: a rose by any other name. Home Health Care Services Quarterly, 8, 2, 23–43.CrossRefGoogle ScholarPubMed
Ashton, T. 2000. New Zealand: long-term care in a decade of change. Health Affairs, 19, 3, 72–85.CrossRefGoogle Scholar
Audit Commission 1999. First Assessment: A Review of District Nursing Services in England and Wales. Audit Commission, London.Google Scholar
Austin, C. 1992. When the whole is more than the sum of its parts: case management issues from a systems perspective. Paper presented at the First International Conference on Long Term Care Case Management, February, Seattle, Washington.Google Scholar
Beardshaw, V. and Towell, D. 1990. Assessment and Care Management: Implications for the Implementation of ‘Caring For People’. Briefing Paper 10, King's Fund Institute, London.Google Scholar
Bergen, A. 1997. The role of community nurses as care managers. British Journal of Community Health Nursing, 2, 10, 466–74.CrossRefGoogle Scholar
Bernabei, R., Landi, F., Gambassi, G., Sgadari, A., Zuccala, G., Mor, V., Rubenstein, L. and Carbonin, P. 1998. Randomised trial of impact of model of integrated care and case management for older people living in the community. British Medical Journal, 316, 7141, 1348–51.CrossRefGoogle ScholarPubMed
Billings, J., Dixon, J., Mijanovich, T., Wennberg, D. 2006. Case finding for patients at risk of readmission to hospital: development of algorithm to identify high risk patients. British Medical Journal, 333, 327, 12 August. doi:10.1136/bmj.38870.657917.AE.CrossRefGoogle ScholarPubMed
Blue, L., Lang, E., McMurray, J., Davie, A., McDonagh, T., Murdoch, D., Petrie, M., Connolly, E., Norrie, J., Round, C., Ford, I. and Morrison, C. 2001. Randomised controlled trial of specialist nurse intervention in heart failure. British Medical Journal, 323, 7315, 715–8.CrossRefGoogle ScholarPubMed
Boaden, R., Dusheiko, M., Gravelle, H., Parker, S., Pickard, S., Roland, M., Sargent, P. and Sheaff, R. 2005. Evercare Evaluation Interim Report: Implications for Supporting People with Long-term Conditions in the NHS. National Primary Care Research and Development Centre, University of Manchester, Manchester, UK.Google Scholar
Bodenheimer, T., Wagner, E. H. and Grumbach, K. 2002. Improving primary care for patients with chronic illness. Journal of the American Medical Association, 288, 14, 1775–9.CrossRefGoogle ScholarPubMed
Bond, G., Evans, G., Salyers, M. P., Williams, J. and Kim, H. W. 2000. Measurement of fidelity in psychiatric rehabilitation. Mental Health Services Research, 2, 2, 75–87.CrossRefGoogle ScholarPubMed
Boyd, M. and Fisher, B. 1996. Community-based case management for chronically ill older adults. Nursing Management, 27, 11, 31–2.CrossRefGoogle ScholarPubMed
Brown, L., Tucker, C. and Domokos, T. 2003. Evaluating the impact of integrated health and social care teams on older people living in the community. Health and Social Care in the Community, 11, 2, 85–94.CrossRefGoogle ScholarPubMed
Brown, R., Peikes, D., Chen, A., Ng, J., Schore, J. and Soh, C. 2007. The Evaluation of the Medicare Coordinated Care Demonstration: Findings for the First Two Years. Mathematica Policy Research Inc., Princeton, New Jersey.Google Scholar
Brown, R., Schore, J., Archibald, N., Chen, A., Peikes, D., Sautter, K., Lavin, B., Aliotta, S. and Ensor, T. 2004. Coordinating Care for Medicare Beneficiaries: Early Experiences of 15 Demonstration Programs, Their Patients, and Providers. Report to the US Congress, Mathematica Policy Research Inc., Princeton, New Jersey.Google Scholar
Carcagno, G. J. and Kemper, P. 1988. The evaluation of the National Long Term Care Demonstration: 1. An overview of the channeling demonstration and its evaluation. Health Services Research, 23, 1, 1–22.Google ScholarPubMed
Challis, D. 1992. Community care of elderly people: bringing together scarcity and choice, needs and costs. Financial Accountability and Management, 8, 2, 77–95.CrossRefGoogle Scholar
Challis, D. 1994. Care management. In Malin, N. A. (ed.), Implementing Community Care. Open University Press, Buckingham, UK, 59–82.Google Scholar
Challis, D. 2003. Achieving coordinated and integrated care among long term care services: the role of care management. In Brodsky, J., Habib, J. and Hirschfeld, M. (eds), Key Policy Issues in Long Term Care. World Health Organisation, Geneva, 139–89.Google Scholar
Challis, D., Chesterman, J., Luckett, R., Stewart, K. and Chessum, R. 2002. Care Management in Social and Primary Health Care: The Gateshead Community Care Scheme. Ashgate, Aldershot, UK.Google Scholar
Challis, D., Darton, R., Johnson, L., Stone, M. and Traske, K. 1995. Care Management and Health Care of Older People: The Darlington Community Care Project. Ashgate, Aldershot, UK.Google Scholar
Chen, A., Brown, R., Archibold, A., Alliotta, S. and Fox, P. D. 2000. Best Practices in Coordinated Care. Mathematica Policy Research Inc., Princeton, New Jersey.Google Scholar
Chen, A., Sautter, K., Schore, J., Brown, R., Peikes, D. and Orzol, S. 2005. The Medical Care Development Medicare Coordinated Care Demonstration Program After One Year. Document PR05-59, Mathematica Policy Research Inc., Princeton, New Jersey.Google Scholar
Cochrane, D. and Fitzpatrick, S. 2005. What works in case management of high risk populations? Health Service Journal, 8 December. Extended version available online at http://goodmanagement-hsj.co.uk/pdf/Casemanagement_081205.pdf [Accessed 21 December 2005].Google Scholar
Curry, N., Billings, J., Darin, B., Dixon, J., Williams, M. and Wennberg, D. 2005. Predictive Risk Project: Literature Review. Available online at http://www.kingsfund.org.uk/health_topics/patients_at_risk/predictive_risk.html [Accessed 24 October 2006].Google Scholar
Davies, B. and Challis, D. 1986. Matching Resources to Needs in Community Care. Gower, Aldershot, UK.Google Scholar
Department of Health 2005 a. Supporting People with Long-term Conditions: An NHS and Social Care Model to Support Local Innovation and Integration. Stationery Office, London.Google Scholar
Department of Health 2005 b. Supporting People with Long-term Conditions: Liberating the Talents of Nurses Who Care for People with Long-term Conditions. Stationery Office, London.Google Scholar
Dixon, J., Lewis, R., Rosen, R., Finlayson, B. and Gray, D. 2004. Can the NHS learn from US managed-care organisations? British Medical Journal, 328, 7433, 223–5.CrossRefGoogle ScholarPubMed
Dorr, D. A., Wilcox, A., Donnelly, S. M., Burns, L. and Clayton, P. D. 2005. Impact of generalist care managers on patients with diabetes. Health Services Research, 40, 5 (part 1), 1400–21.CrossRefGoogle ScholarPubMed
Drennan, V., Goodman, C. and Leyshon, S. 2005. Supporting People with Long Term Conditions: Supporting Experienced Hospital Nurses to Move into Community Matron Roles. Department of Health, London. Available online at http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4123450 [Accessed 8 May 2009].Google Scholar
Eastwood, A. J. and Sheldon, T. A. 1996. Organisation of asthma care: what difference does it make? A systematic review of the literature. Quality and Safety in Health Care, 5, 3, 134–43.CrossRefGoogle ScholarPubMed
Enguidanos, S. M., Gibbs, N. E., Simmons, W. J., Savoni, K. J., Jamison, P. M., Hackstaff, L., Griffin, A. M. and Cherin, D. A. 2003. Kaiser Permanente Community Partners Project: improving geriatric care management practices. Journal of the American Geriatrics Society, 51, 5, 710–14.CrossRefGoogle Scholar
Fisher, M. 1990–91. Defining the practice content of care management. Social Work and Social Sciences Review, 2, 3, 204–230.Google Scholar
Fitzgerald, J. F., Smith, D. M., Martin, D. K., Freedman, J. A. and Katz, B. P. 1994. A case manager intervention to reduce readmissions. Archives of Internal Medicine, 154, 15, 1721–9.CrossRefGoogle ScholarPubMed
Gagnon, A., Schein, C., McVey, L. and Bergman, H. 1999. Randomized controlled trial of nurse case management of frail older people. Journal of the American Geriatrics Society, 47, 9, 1118–24.Google ScholarPubMed
Hallberg, I. R. and Kristensson, J. 2004. Preventive home care of frail older people: a review of recent case management studies. Journal of Clinical Nursing, 13, S2, 112–20.CrossRefGoogle ScholarPubMed
Hofmarcher, M., Oxley, H. and Rusticelli, E. 2007. Improved Health System Performance Through Better Care Coordination. Health Working Paper 30, Organisation for Economic Cooperation and Development, Paris. Available online at http://www.oecd.org/dataoecd/22/9/39791610.pdf [Accessed 9 February 2009].Google Scholar
Hokenstad, M. and Johansson, L. 1996. Eldercare in Sweden: issues in service provision and case management. Journal of Case Management, 5, 4, 137–41.Google ScholarPubMed
Hutt, R., Rosen, R. and McCauley, J. 2004. Case Managing Long-term Conditions: What Impact Does it Have in the Treatment of Older People? King's Fund, London.Google Scholar
Huxley, P., Hagan, T., Hennelly, R. and Hunt, J. 1990. Effective Community Mental Health Services. Gower, Aldershot, UK.Google Scholar
Johri, M., Beland, F. and Bergman, H. 2003. International experiments in integrated care for the elderly: a synthesis of the evidence. International Journal of Geriatric Psychiatry, 18, 3, 222–35.CrossRefGoogle ScholarPubMed
Kemper, P. 1988. The evaluation of the National Long Term Care Demonstration: 10. Overview of the findings. Health Services Research, 23, 1, 161–74.Google ScholarPubMed
Kharicha, K., Levin, E., Iliffe, S. and Davey, B. 2004. Social work, general practice and evidence-based policy in the collaborative care of older people: current problems and future possibilities. Health and Social Care in the Community, 12, 2, 134–41.CrossRefGoogle Scholar
Lamb, G. S. 1992. Conceptual and methodological issues in nurse case management research. Advances in Nursing Science, 15, 2, 16–24.CrossRefGoogle ScholarPubMed
Landi, F., Lattanzio, F., Gambassi, G., Zuccala, G., Sgadari, A., Panfilo, M., Ruffilli, M. and Bernabei, R. 1999. A model for integrated home care of frail older patients: the Silver Network project. Aging Clinical and Experimental Research, 11, 4, 262–72.CrossRefGoogle Scholar
Landi, F., Onder, G., Russo, A., Tabaccanti, S., Rollo, R., Federici, S., Tua, E., Cesari, M. and Bernabei, R. 2001. A new model of integrated home care for the elderly: impact on hospital use. Journal of Clinical Epidemiology, 54, 9, 968–70.CrossRefGoogle ScholarPubMed
Leung, A. C., Liu, C., Chow, N. W. and Chi, I. 2004. Cost–benefit analysis of a case management project for the community-dwelling frail elderly in Hong Kong. Journal of Applied Gerontology, 23, 1, 70–85.CrossRefGoogle Scholar
Long, M. 2002. Case management model or case manager type? That is the question. Health Care Manager, 20, 4, 53–65.CrossRefGoogle ScholarPubMed
Loveman, E., Royle, P. and Waugh, N. 2003. Specialist nurses in diabetes mellitus. Cochrane Database of Systematic Reviews, 2, CD003286. doi: 10.1002/14651858.CD003286. Available online at http://mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD003286/frame.html [Accessed 9 February 2009].CrossRefGoogle Scholar
Lynch, J., Forman, S., Graff, S. and Gunby, M. 2000. High-risk population health management: achieving improved patient outcomes and near-term financial results. American Journal of Managed Care, 6, 7, 781–91.Google ScholarPubMed
Lyon, D., Miller, J. and Pine, K. 2006. The Castlefields integrated-care model: the evidence summarised. Journal of Integrated Care, 14, 1, 7–12.CrossRefGoogle Scholar
Lyon, J. C. 1993. Models of nursing care delivery and case management: clarification of terms. Nursing Economics, 11, 3, 163–78.Google ScholarPubMed
Maravilla, V., Graves, M. and Newcomer, R. 2005. Development of a standardized language for case management among high-risk elderly. Lippincotts Case Management, 10, 1, 3–13.CrossRefGoogle ScholarPubMed
Marshall, B., Long, M., Voss, J., Demma, K. and Skerl, K. 1999. Case management of the elderly in a health maintenance organization: the implications for program administration under managed care/practitioner application. Journal of Healthcare Management, 44, 6, 477–91.CrossRefGoogle Scholar
Mays, N., Pope, C. and Popay, J. 2005. Systematically reviewing qualitative and quantitative evidence to inform management and policy-making in the health field. Journal of Health Services Research and Policy, 10, supplement 1, 6–20.CrossRefGoogle ScholarPubMed
Moher, D., Schulz, K. F. and Altman, D. G.for the CONSORT Group 2001. The CONSORT statement: revised recommendations for improving the quality of reports of parallel-group randomised trials. The Lancet, 357, 9263, 1191–4.CrossRefGoogle Scholar
Moxley, D. 1989. The Practice of Case Management. Sage, Newbury Park, California.Google Scholar
National Health Priority Action Council 2006. National Chronic Disease Strategy. Australian Government Department of Health and Ageing, Canberra.Google Scholar
Newcomer, R., Maravilla, V., Faculjak, P. and Graves, M. T. 2004. Outcomes of preventive case management among high-risk elderly in three medical groups: a randomized clinical trial. Evaluation and the Health Professions, 27, 4, 323–48.CrossRefGoogle ScholarPubMed
Norris, S. L., Nichols, P. J., Caspersen, C. J., Glasgow, R. E., Engelgau, M. M., Jack, J., Isham, G., Snyder, S. R. and Carande-Kulis, V. G. 2002. The effectiveness of disease and case management for people with diabetes: a systematic review. American Journal of Preventive Medicine, 22, 4, supplement 1, 15–38.CrossRefGoogle ScholarPubMed
Petticrew, M. and Roberts, H. 2006. Systematic Reviews in the Social Sciences: A Practical Guide. Blackwell, Oxford.CrossRefGoogle Scholar
Phelan, E., Cheadle, A., Schwartz, S., Snyder, S., Williams, B., Wagner, E. and LoGerfo, J. 2003. Promoting health and preventing disability in older adults: lessons from intervention studies carried out through an academic-community partnership. Family and Community Health, 26, 3, 214–20.CrossRefGoogle ScholarPubMed
Popay, J., Roberts, H., Sowden, A., Petticrew, M., Arai, L., Rodgers, M., Britten, N., Roen, K. and Duffy, S. 2005. Guidance on the Conduct of Narrative Synthesis in Systematic Reviews. Version 2, Division of Health Research, University of Lancaster, Lancaster, UK.Google Scholar
Pugh, L., Havens, D., Xie, S., Robinson, J. and Blaha, C. 2001. Case management for elderly persons with heart failure: the quality of life and cost outcomes. MedSurg Nursing, 10, 2, 71–8.Google Scholar
Raine, R., Haines, A., Sensky, T., Hutchings, A., Larkin, K. and Black, N. 2002. Systematic review of mental health interventions for patients with common somatic symptoms: can research evidence from secondary care be extrapolated to primary care? British Medical Journal, 325, 7372, 1082.CrossRefGoogle ScholarPubMed
Renders, C. M., Valk, G. D., Griffin, S., Wagner, E. H., van Eijk, J. Th. M. and Assendelft, W. J. J. 2001. Interventions to improve the management of diabetes mellitus in primary care, outpatient and community settings. Cochrane Database of Systematic Reviews, 1, CD001481. doi: 10.1002/14651858.CD001481.Google ScholarPubMed
Richards, S. and Coast, J. 2003. Interventions to improve access to health and social care after discharge from hospital: a systematic review. Journal of Health Services Research Policy, 8, 3, 171–9.CrossRefGoogle ScholarPubMed
Ritchie, C., Wieland, D., Tully, C., Rowe, J., Sims, R. and Bodne, E. 2002. Coordination and advocacy for rural elders (care): a model of rural case management with veterans. The Gerontologist, 42, 3, 399–405.CrossRefGoogle Scholar
Rosen, A. and Teesson, M. 2001. Does case management work? The evidence and the abuse of evidence-based medicine. Australian and New Zealand Journal of Psychiatry, 35, 6, 731–46.CrossRefGoogle ScholarPubMed
Ross, F. and Tissier, J. 1997. The care management interface with general practice: a case study. Health and Social Care in the Community, 5, 3, 153–61.CrossRefGoogle Scholar
Rothman, A. and Wagner, E. 2003. Chronic illness management: what is the role of primary care? Annals of Internal Medicine, 138, 3, 256–61.CrossRefGoogle ScholarPubMed
Rummery, K. and Glendinning, C. 2000. Primary Care and Social Services: Developing New Partnerships for Older People. Radcliffe Medical Press, Abingdon, UK.Google Scholar
Sargent, P., Pickard, S., Sheaff, R. and Boaden, R. 2007. Patient and carer perceptions of case management for long-term conditions. Health and Social Care in the Community, 15, 6, 511–9. doi: 10.1111/j.1365-2524.2007.00708.x.CrossRefGoogle ScholarPubMed
Schein, C., Gagnon, A. J., Chan, L., Morin, I. and Grondines, J. 2005. The association between specific nurse case-management interventions and elder health. Journal of the American Geriatrics Society, 53, 4, 597–602.CrossRefGoogle ScholarPubMed
Schore, J., Brown, R. and Cheh, V. 1999. Case management for high-cost Medicare beneficiaries. Health Care Financing Review, 20, 4, 87–101.Google ScholarPubMed
Schraeder, C., Dworak, D., Stoll, J. F., Kucera, C., Waldschmidt, V. and Dworak, M. P. 2005. Managing elders with co-morbidities. Journal of Ambulatory Care Management, 28, 3, 201–9.CrossRefGoogle Scholar
Shortell, S. M., Marsteller, J. A., Lin, M., Pearson, M. L., Wu, S.-Y., Mendel, P., Cretin, S. and Rosen, M. 2004. The role of perceived team effectiveness in improving chronic illness care. Medical Care, 42, 11, 1040–8.CrossRefGoogle ScholarPubMed
Singh, D. 2005 a. Which Staff Improve Care for People with Long-term Conditions? A Rapid Review of the Literature. NHS Modernisation Agency and University of Birmingham Health Service Management Centre, Birmingham, UK.Google Scholar
Singh, D. 2005 b. A Rapid Review of the Current State of Knowledge Regarding Lay-led Self-management of Chronic Illness. NHS Modernisation Agency and University of Birmingham Health Service Management Centre, Birmingham, UK.Google Scholar
Singh, D. and Ham, C. 2006. Improving Care for People with Long-term Conditions: A Review of UK and International Frameworks. NHS Institute for Innovation and Improvement and University of Birmingham Health Service Management Centre, Birmingham, UK.Google Scholar
Stewart, S. and Blue, L. 2001. Key components of specialist nurse-led programmes in chronic heart failure. In Stewart, S. and Blue, L. (eds), Improving Outcomes in Heart Failure: A Practical Guide to Specialist Nurse Intervention. BMJ Books, London, 114–8.Google Scholar
Strike, K. and Posner, G. 1983. Types of synthesis and their criteria. In Ward, S. and Reed, L. (eds), Knowledge Structure and Use: Implications for Synthesis and Interpretation. Temple University Press, Philadelphia, Pennsylvania, 343–62.Google Scholar
Taylor, S., Bestall, J., Cotter, S., Falshaw, M., Hood, S., Parsons, S., Wood, L. and Underwood, M. 2005. Clinical service organisation for heart failure. Cochrane Database of Systematic Reviews, 2, CD002752. doi: 10.1002/14651858.CD002752.pub2.Google ScholarPubMed
Tucker, C. and Brown, L. 1997. Moving Towards the Integration of Health and Social Care: An Evaluation of Different Models for Accessing Community Care Services for Adults and their Carers. Wiltshire Social Services and Department of Social and Policy Sciences, University of Bath, Bath, UK.Google Scholar
van Haastregt, J. C. M., Diederiks, J. P. M., van Rossum, E., de Witte, L. P. and Crebolder, H. F. J. M. 2000. Effects of preventive home visits to elderly people living in the community: systematic review. British Medical Journal, 320, 7237, 754–8.CrossRefGoogle ScholarPubMed
Wagner, E. H. 1998. Chronic disease management: what will it take to improve care for chronic illness? Effective Clinical Practice, 1, 1, 2–4.Google ScholarPubMed
Weiner, K., Hughes, J., Challis, D. and Pedersen, I. 2003. Integrating health and social care at the micro level: health care professionals as care managers for older people. Social Policy and Administration, 37, 5, 498–515.CrossRefGoogle Scholar
Weingarten, S. R., Henning, J. M., Badamgarav, E., Knight, K., Hasselblad, V., Gano, A. Jr. and Ofman, J. J. 2002. Interventions used in disease management programmes for patients with chronic illness: which ones work? Meta-analysis of published reports. British Medical Journal, 325, 7370, 925–32.CrossRefGoogle ScholarPubMed