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Case Management – long term conditions

Case Management – long term conditions. Liz Thwaite ANP Craven Collaborative Care Team. Aims of session. To develop an understanding of Case Management Using the case of Fred and Norma to illustrate how to case manage proactively.

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Case Management – long term conditions

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  1. Case Management – long term conditions Liz Thwaite ANP Craven Collaborative Care Team

  2. Aims of session • To develop an understanding of Case Management • Using the case of Fred and Norma to illustrate how to case manage proactively. • Demonstrate how good case management reduces avoidable emergency admissions. • What constitutes good case management.

  3. Over 15 million people in the UK are living with a long term condition and currently in excess of 70% of the Health & Social Care budget is spent treating these conditions.

  4. Services that are or could be involved at any stage. • Community Matron • District Nurse • Optician • Occupational Therapist • Nurse Specialists • Voluntary agencies • Age uk • Secondary care consultants. • Community Geriatrician • Carers resource • Pensions agency • Community Mental Health team • Podiatrist • Pharmacist – local chemist • General Practitioner • Telehealth • Dietician • Physiotherapist • Palliative care team • Intermediate care team • Step up beds • Practice nurse • Carers – formal and informal • Social services • Community Equipment store • Day care/respite • Handiman scheme – key safe • Careline • SALT

  5. Fred and Norma

  6. Freds Progress. • Fred remains alert and orientated. He is eating and drinking. • He is breathless on exertion. • His NEWS has increased from an aggregate of 3 to 5. • The intermediate care team contact you for advice. • What further information do you need? • What action are you going to take?

  7. Fred has recovered • He is discharged from intermediate care team, social services enabling team are now taking over. • What on going support will Fred need?

  8. And finally Norma • What has come to light since we have been caring for Fred? • What can we do to support Norma? • What follow up support might Norma need. • What support will Fred need in future in his role as carer for Norma.

  9. Key points to remember • Communication – timely, pick up the phone, send a task, fax the consultation, bleep us. • Integration with and use of wider multidisciplinary team, including good links with secondary care specialists. • The GP is a vital part of the case management process – it will not succeed without your support.

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