Community Matrons & Case Management: Why Bother? Because...

1. Community matrons & case management Why bother?

2. Because… • Need • Policy requirement • Patient experience • Cost savings

3. ORIGINAL EVIDENCE BASE

4. PSA target • To improve health outcomes for people with long term conditions by offering a personalised care plan for vulnerable people most at risk, and to reduce emergency bed days by 5% by 2008 through improved care in primary and community settings • Performance indicators (locally agreed in LDPs); • - Emergency Bed Days • - Number of VHIUs • - Numbers of community matrons • - Numbers of case managers

5. Further White Paper commitments • Universal case management for VHIUs • Personal health and care plans for those with long term health and social care needs by 2008, and for everyone by 2010 • Single point of contact 24/7 for people with complex needs (e.g. linking case management and out of hours) • Also core element of Fitness for Purpose Programme Care Pathway Management Diagnostic

6. are level 3 case management high complexity level 2 disease/care management high risk professional care level 1 self care 70-80% of CDM population self care support/ management

7. Who are the VHIUs? Half of all very high intensity users are aged 75 or over, compared to just over a quarter of all hospital inpatients

8. A growing challenge.. Over the next three years, the population aged 75 or older will increase at twice the rate of the population as a whole. In addition, the numbers of people in their 60s is increasing much faster still (3.4% per year) and these people are potentially about to become much higher users of emergency hospital care.

9. In summary… • Few patients account for much health spending • Many of these have multiple long-term conditions • Trends are for this group to increase in number, causing a significant challenge to the healthcare system Also, those with complex healthcare needs - are often not having those met • often have poor service experience This compelling case remains as strong as ever

10. What is the role of a case manager? • Undertaking a comprehensive health and social care assessment to develop a care plan and initiate interventions to • improve quality of life, • maintain well being • Providing anticipatory and crisis care • Reducing fragmentation of care A community matron in addition is; • An experienced nurse who provides advanced nursing care and case management to people with multiple complex long term conditions. This includes; • Managing the acute execrations of chronic illness e,g IV hydration and antibiotic therapy • Monitoring and managing medicines

11. Community matrons need • High level of clinical knowledge in prevalent conditions and evidence based practice • Broad levels of knowledge: • social and medical models of health • physical and mental health • Ability to manage risk • Advanced skills in assessment, medicines management- concordance, interpersonal skills, ‘courageous conversations’, promoting self-management • Professionalism: taking responsibility and delivering outcomes.

12. Pattern of bed use of VHIUs This shows increasing hospital use in prior year, a big spike of activity in their most intensive year and slower tail off

13. IMPACT OF CASE FINDING TECHNIQUES Threshold modelling • Of form “people meeting 3 or more of following criteria…” • Predisposed to selection bias and too reactive • Research suggests this is half as accurate as predictive/regression models Clinical knowledge • Clinician refers patients for case management • Likely to refer people that have been high risk in past • Research suggests there are low levels of predictive accuracy using this method. Predictive modelling • Uses data on clinical history to predict future healthcare need • Many different techniques/approaches that have varying levels of success, however • Research consistently finds this the best method of case finding Kings Fund study into different case finding methods showed significant differences in impact of case management depending on which technique is adopted Prediction & clinical knowledge • This is usually where predictive modelling outputs are combined with clinical knowledge • This is the most common current method of case finding in England. • No research evidence that say how this method performs relative to the predictive modelling alone

14. Potential benefits from predictive tools If patients are identified during the year they are most intensive users [Threshold models & clinical knowledge], case management could save 9% resource use over these ten years However, if patients are identified in the year prior to which they are most intensive users [predictive models], case management could save 20% resource use over the ten years Saving (in light blue) that could be achieved assuming case management can prevent 10% admissions and reduce length of stay by 20% on average

15. The Combined Predictive Model Commissioned by DH and East of England SHA (on behalf of all English SHAs) Developed by the King’s Fund, Health Dialog Analytic Solutions and New York University

16. The Combined Predictive Model • Uses hospital inpatient, outpatient, A&E and GP practice data (PARR just uses inpatient data) • Improves predictive accuracy for very high risk patients • Predicts risk of hospital admission for those patients who have not experienced a recent emergency admission • Stratifies risk across all patients in a given health economy to help NHS organisations understand drivers of utilisation at all levels

17. The Combined Predictive Model • Prevention and wellness promotion for relatively low risk patients • Supported self care interventions for moderate risk patients • Early intervention care management for patients with emerging risk • Intensive case management for very high risk patients

18. Enhanced Positive Predictive Value over PARR Kate Gill, EOE SHA

19. Introduces a new and different patient population

20. The Combined Predictive Model • Not a software tool like PARR – more complicated to implement • Will require some programming skills from PCT informatics teams • Will require sharing of GP electronic records • GPs need to buy into it. • Patient confidentiality is not an issue – PIAG guidance on this will be made available • Central data warehousing is needed

21. Admissions PREDICTED 0 PARR Score 98 100 Admissions OBSERVED 0 PARR Score 98 100 Dr Geraint Lewis, Croydon PCT

22. Financial benefits4 PCT findings In all areas there was a consistent cost saving (ranging from £17-81K per community matron) The financial impact of case management was greater in Luton. Here, they used PARR case finding tool + had community matrons who were fully trained and experienced in the role.

23. Not only inpatient care reduced There was a consistent fall in activity over and above expected fall for very high intensity users in all areas Source: Cornwall PCTs

24. Impact of community matrons increased over time Source: Epping Forrest PCT

25. Patient satisfaction high Chart: High levels of improved outcomes & patient satisfaction, Luton PCT

26. What have we learnt? Feedback from a number of sites has pointed to common areas, which are key to the effectiveness of case management • Strategic and business /commissioning plans • Implementation plans with a specified model to integrate CMs into local healthcare systems & project manager to undertake service redesign • Operational agreements which give CMs authority to coordinate services (& direct others) • Case finding model using predictive tool • Workforce and training plans

27. What have we learnt? • Support for clinical decision making & a clinical governance assurance process • An agreed framework to support systematic assessments of patients & personalised care plans • Tools to enable patients & carers to self care and make informed decisions and choices • IT systems which enable shared care between CMs, GPs and others & enable data collection to review progress