1. Clinical case management and its role in the continuum of care

2. Introduction Background to post Elements of case management Progress to date How does it work in practice? Conclusions

3. Background

4. Case management is A strategy used to create a complete loop or network of services for a predefined population of patients. Case management cuts across formal hierarchies and services to produce a matrix of services

5. Clinical Case Management Clinical case management has at its heart a systematic approach to care The goals of case management is providing quality health care along a continuum, decreasing fragmentation of care across many settings, enhancing the client’s quality of life, and supporting value for money

6. Its about doing things differently? Bridging the gap – Integrated Care goes to the heart of quality of care for older people “ I expect person centred coordinated care ”

7. The Continuum of Care

8. Elements of Case Management Level 3 – very high intensity users of unplanned hospital care. Level 2 – Complex single needs or multiple conditions Responsive specialist services, multi disciplinary teams & disease specific care pathways Level 1 – helping patients & carers develop the knowledge, skills & confidence to care for themselves and their condition effectively 70 – 80% long term illness 70 – 80% long term illness 16-26% 4%4% 4%4%

9. Important service-level design elements of care for older people with chronic and multiple conditions Comprehensive Assessment Care Planning Single Point of Entry Care Co- ordination

10. Progressing that ICP – 2013-2015 Older Person Community- Facing Geriatrician Acute Care Access Respite/ Assessment and Rehabilitation Bed Access Day Hospital- Rapid Access Home Care and Community Intervention Team Clinical Case Manager for older persons ( 2013) Old Age Psychaitry

11. Progress to date 4 community based posts in Dublin North working in partnership with Consultant Geriatricians and many others Development of enhanced ambulatory care pathways for older people to support admission avoidance including end of life The role has facilitated real integration across traditional acute and community boundaries (development of community virtual ward )

12. Phone call from GP to case manager 90 yo F, frail, recent discharge acute hospital, multiple co-morbidities, not doing well at home, not eating, not drinking, carer stress++ CGA at home with case manager next morning Decision to remain at home with supports Home care package Community Intervention Team Care Plan Interface Geriatrician Full Clinical review Anticipatory care Plan Respite options Plan for monitoring and follow up ? What to do Options Discussed ? Acute Hospital ?OPD ?Day Hospital ?Assessment at home MK doing well at home – 6 months later!

13. Challenges Learn collaborative working Coordination of care Value placed on high touch Vs high tech care Working across organisational and funding silos – ICT support Measure our success

14. Conclusion The success or otherwise of developments such as the clinical case manager relies on access to responsive management teams and services, clinical, technological and managerial supports Clinical case mangers integrate and connect services around the client The evidence to date speaks for itself!

15. Finally