Care coordination

“Case Management models will not deliver better care for patients and produce cost savings unless they are well designed, involve appropriately and professionally trained case managers and teams and be embedded in a wider system of care that supports and values integrated and coordinated care.”

Neil Goodwin, Kings Fund and The International Federation for Integrated Care 

Conrane was the first group to implement a successful, best-practice locality model for care coordination of the 5% of the population who can consume up to 50% of local healthcare resources. This group are mostly patients with multiple long-term conditions alongside psychological and social needs including impaired functioning. The model is holistic, anticipatory integrated, primary-care-linked and is based on full patient partnership and a personalised care planning approach. Adapted from health maintenance organisations in the USA, it was first implemented in Castlefields Health Centre in 2000 – the practice where Prof David Colin-Thome was then the senior partner.

We subsequently implemented it in over 20 PCTs including across Surrey, Sussex and Central and North London. Led by nurses trained in case management and long-term conditions, the model has recently been validated in control trials by Kaiser Permanente.  This work was recently given an award by the BMJ in its “Getting Research into Practice” category. The model is most effective within an integrated care system at locality level. 

This approach parallels the more successful accountable care organisations in the US where care coordination is a core service. One recent example, highlighted by the Commonwealth Fund, reports these outcomes in one of the national demonstration Pioneer ACOs which is exceeding its minimum savings target and achieving all its quality goals. See and download report at https://www.commonwealthfund.org/publications/case-studies/2016/oct/guided-care  The Guided Care study has demonstrated improved outcomes, patient satisfaction and reduction in hospital admissions and costs which generate a return on investment for the service of nearly 100%. 

Using the outcomes framework shown below, nurse practioners in our projects have delivered the following outcomes:

For patients – a sense of greater control over their health needs, deepened understanding of early warning signs, improved satisfaction and sense of well-being leading to greater self-care and treatment adherence.

For GPs and case managers – decreased primary care workload, reductions in pharmacy costs, improvements in QOF performance and pro-active care process.

In terms of utilisation – in the first 6-12 months of the implementation, both admission rates and GP consultation rates ca be  dramatically reduced amongst the managed population – well below the level expected due to “regression to the mean”.   As  a result overall unscheduled admissions rates are impacted.

Effective case management is a complex clinical process which needs highly competent practitioners. Conrane and its partners can offer:

  • Predictive modelling drawing on primary and secondary care data to identify the patient cohort including the Johns Hopkins ACG tool
  • Training and mentorship of clinical case managers
  • Development of an operational policy which critically integrates the service with the GP and primary care team as well as associated services in the community including re-ablement
  • Tools for care planning and delivery and impact assessment

Our model for Best Practice Case Management

Our Best Practice Case Management Process

 

What our clients say:

“Conrane are engaging with partners across both commissioning and provider organisations to facilitate a collaborative approach (to care coordination) which has aided the success of the pilot. Early indications are excellent, patient and staff feedback, better medicines management and a fall in the use of secondary care hospital admissions, therefore we have extended the pilot for a further year.”

North Kirklees CCG 2016

 

For more detail please download the information sheets from our Resources page.