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ABSTRACT

Introduction: Case management roles by nurses (amongst others) has been promoted in the UK as a mechanism for improving service delivery for people with complex long term conditions and, in England, for reducing emergency admissions of frail older people¹. The evaluation of one pilot, Evercare, reported that it did not deliver the benefits hoped for². Although there is increasing knowledge internationally on the impact of case management, it is still not clear which elements, delivered by whom, in which settings in the UK are effective. In order to begin to address these questions, there is a requirement to describe the different forms that nurse case management takes within the primary care setting. This survey was undertaken to establish the range of nurse case management models in England as part of a study funded by the NHS Service Delivery and Organisation research programme.
Methods: A survey of a purposive sample (n=40) of lead nurses in primary care organisations in all 9 strategic health authorities. The survey was conducted by telephone interview. The data was summarised and confirmed with the informant before descriptive and thematic analysis.
Results: All informants identified nurses in case management roles in primary care and community settings. A range of models were identified that incorporated a variety of relationships with general practitioners, acute sector consultants, intermediate care teams and social workers. The models also varied in the types of clinical activity, co-ordinating activities, referral rights and access to budgets for care. The most commonly reported patient conditions that were being case managed were chronic obstructive pulmonary disease, coronary heart disease and heart failure. The caseloads were reported to range for 14 to 85. The number of nurses reported in these roles in the local ranged from 2 - 15. Finance was reported to be the key determinant of numbers in post. Most service monitoring was focused on the effect on emergency admissions of people aged over 75 years.
Conclusions: The survey demonstrates that despite policies that imply a single model of nurse case management, local contexts and stakeholders influence the implementation. As a consequence there are a range of models of nurse case managers in primary care and community settings. The next phase of this study will examine the contribution these make to the overall treatment and care of patients.

References:
1. DH(England) 2005 Supporting people with long term conditions ; a NHS and social care model . Leeds : Department of Health.
2. Gravelle H, Dusheiko M, Sheaff R, Sargent P, Boaden R, Pickard S, Parker S, Roland M. Impact of case management (Evercare) on frail elderly patients: controlled before and after analysis of quantitative outcome data. BMJ. 2007 Jan 6;334(7583):31. Epub 2006 Nov 15.

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