1. Community matrons & case management
Why bother?

2. Because…
Need
Policy requirement
Patient experience
Cost savings

3. ORIGINAL EVIDENCE BASE
Original analysis - small numbers of patients using many bed days and therefore accounting for much spending

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 professional care self care case management level 3
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?
Age along bottom axis, % total inpatients up side
Pink line shows age distribution for VHIUs
Black shows age distribution for all hospital inpatients
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
When those using many bed days were looked at in more detail, a pattern was noticed
Even if nothing is done, admission rates fall after peak year
‘regression to the mean’

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.
Kings Fund study into different case finding methods showed significant differences in impact of case management depending on which technique is adopted
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
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
The ability to identify emerging risk patients will enable NHS organisations to take a more strategic approach to their care management interventions. For example PCTs will be able to design and implement interventions and care pathways along the continuum of risk ranging from:

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

19. Introduces a new and different patient population
This graph illustrates patients identified by the Combined Model at different cuts of population who had no previous admission (purple), those who were identified as low risk by PARR (red) and those identified as high risk by PARR.
The addition of patients who would have been missed by PARR altogether due to lack of prior inpatient admissions and patients who had been identified at a much lower risk level by PARR due to its reliance on inpatient only data is significant. The Combined Model’s use of richer data sets allow for risk stratification at levels more conducive to effective early intervention as it identifies patients before they have deteriorated to point of multiple inpatient admissions.

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
Help with implementation can be given but there may be a cost for local implementation and calibration.

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

22. Financial benefits 4 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.
Savings calculated using inpatient costs , using the England average cost of a non-elective hospital admission, minus costs of CMs (salary, training costs and support costs (primarily IT and case finding support at the PCT).
NB Stockport only included salary and training costs.

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
. This was over one year: the change from baseline of measured against those of
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? Strategic and business /commissioning plans
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