Case Management of Long-Term Conditions: Principles and Practice for Nurses

Contents......Page 5
Introduction......Page 11
Introduction......Page 15
Primary care management of long-term conditions......Page 16
How management approaches have been developed......Page 17
Developing and delivering care......Page 18
Future of care......Page 19
The impact and cost of chronic disease......Page 20
Identifying patients who require case management......Page 21
Embedding evidence in practice......Page 22
Making progress in the management of chronic conditions......Page 23
Developing case management and care delivery......Page 24
Case management in the National Health Service......Page 25
Partnerships and expectations......Page 27
References......Page 29
Introduction......Page 32
The context for case management in the NHS......Page 34
Impact of managed care models......Page 35
The Alaskan Medical Service......Page 36
Kaiser Permanente (North California)......Page 38
HealthPartners (Minnesota)......Page 39
UnitedHealth Europe Evercare......Page 40
Amsterdam HealthCare System (the Netherlands)......Page 41
PACE (United States)......Page 42
Pfizer (United States)......Page 43
Models in use in England......Page 44
Case management models in the NHS......Page 46
Joint NHS and social care......Page 50
Evaluation......Page 52
Conclusion......Page 54
References......Page 55
Introduction......Page 57
Development of the competency framework......Page 58
The competencies: what are they?......Page 60
Domain A: advanced clinical nursing practice......Page 61
Domain B: leading complex care co-ordination......Page 63
Domain D: managing cognitive impairment and mental well-being......Page 66
Domain E: supporting self-care, self-management and enabling independence......Page 69
Domain F: professional practice and leadership......Page 71
Domain G: identifying high-risk people, promoting health and preventing ill health......Page 72
Domain H: end-of-life care......Page 73
Domain I: interagency and partnership working......Page 74
What the competencies aim to do......Page 75
Developing educational models to develop competencies......Page 76
References......Page 78
The areas of competence and deliverables for patients: Leading complex care co-ordination......Page 80
Identifying high-risk patients, promoting health and preventing ill health......Page 88
Interagency and partnership working......Page 91
References......Page 96
Advanced clinical nursing practice......Page 99
Proactively manage complex long-term conditions......Page 105
Professional practice and leadership......Page 108
Managing care at the end of life......Page 111
Conclusion......Page 115
References......Page 116
Policy drivers for the care of older people......Page 119
Health and social care integration......Page 122
Cost of care for older people......Page 123
What do people expect in old age and how will these services be commissioned?......Page 125
What does case management offer to older people?......Page 126
Impact of case management on older people......Page 128
Outcomes for older people......Page 132
Conclusions......Page 133
References......Page 134
Introduction......Page 137
Integrated Cancer Care Programme......Page 139
Preparing for the pilot programmes......Page 141
Delivering the pilots......Page 143
Programme outcomes......Page 144
Case Management and ICCP......Page 145
Case management competencies – what can/should patients expect?......Page 146
The real need for competencies......Page 151
Advanced care planning......Page 153
Conclusion......Page 154
References......Page 156
What is leadership?......Page 158
What does leadership provide?......Page 159
Leadership framework in the NHS......Page 160
Skills in leadership......Page 161
Setting targets and delivering outcomes......Page 162
Empowerment and influencing......Page 163
Other leadership frameworks......Page 164
Impact on organisations......Page 167
Leadership in case management......Page 168
Leadership and change......Page 169
Leadership is in every role......Page 170
Advanced practice......Page 171
Prescribing......Page 172
Advanced practice in long-term conditions......Page 173
Conclusions......Page 174
References......Page 175
What is self-care?......Page 178
Self-care and practitioners......Page 181
Expert Patient Programme......Page 182
Effectiveness of self-care programmes......Page 183
Promoting self-care: staff role......Page 184
Self-care: models......Page 185
Self-care: the evidence base......Page 187
Using information and technology for self-care......Page 189
How do we engage patients in self-care?......Page 193
Conclusions......Page 194
References......Page 197
Introduction......Page 199
What do patients want from care?......Page 200
Reported outcomes from management of long-term conditions......Page 201
Do patients really see improvement?......Page 202
Understanding the patient experience, how we find out?......Page 204
Other assessments of user/patient experiences......Page 206
Outcomes of care and patient experience......Page 209
Experience in case management......Page 211
Partnerships with patients: impact on experience......Page 213
Quality for patients......Page 214
Conclusions......Page 215
References......Page 217
C......Page 221
I......Page 222
N......Page 223
P......Page 224
S......Page 225
W......Page 226