Nick Goodwin: Case management and the urgent need for primary care investment

Nick GoodwinOver the next decade and beyond, the ageing population and the increased prevalence of chronic disease requires a step change in the way services are delivered. There needs to be a strong re-orientation away from the current emphasis on acute care towards prevention, self care, more consistent standards of primary care, and care that is well co-ordinated and integrated.

This new model of “integrated care” needs to be less focused on treating people when they become ill, and more focused on prevention and supporting people to manage their own healthcare issues in the home. In the longer term, it will only be through this approach that the foundations for a more sustainable model of care delivery can be created in the long term.

Case management is a key tool in supporting this transition and has become widely deployed internationally as a means to target individuals with chronic conditions who are at the greatest risk of an emergency admission. The premise of the model is that proactive, community-based care led by nurses and multi-disciplinary teams is more cost-effective than downstream acute care since the costs of the service can be offset by reducing expensive hospital utilisation (principally in terms of unscheduled hospital admissions) or long term residential home stays.

The truth, however, is that the evidence base for the effectiveness of case management is decidedly mixed. Whilst the majority of schemes show that the experience of service users can improve, most have not significantly reduced emergency admissions and costs. Hence, case management can become an additional expense on the system rather than a solution to the problem of delivering high quality care within a limited budget resource.

However, the evidence base can be misleading. Whilst many case management programmes have clearly not been as successful as they could have been, there is evidence to suggest that—where it is implemented effectively—it can improve the experiences of users and carers, support better care outcomes, enable independent living, and reduce hospital based services to the extent it becomes a cost effective solution. A number of key factors must be present, including teams of well trained case managers integrated into primary care practices with the capacity and range of skills that can both treat and co-ordinate care services for people across multiple care settings.
More fundamentally, when selecting individuals for intensive case management, it is important to make an assessment of whether they will really benefit from it. People are too often selected when they could very well manage their own care effectively, or selected for care support when their needs probably mean that they would be better off in a hospital or long term residential care support setting.

Perhaps the biggest failing can occur where the case management approach happens in isolation. The goals of case management are undermined if there is no availability or access to an extended range of primary care services or community-based packages of social care that can enable rehabilitation, re-ablement, or support for independent living. The lack of ability to provide care out-of-hours means co-ordination of care can further be compromised. Most unnecessary emergency admissions in case management schemes happen due to these problems.

Case management clearly has its part to play in meeting the growing needs of older people and those with complex chronic illnesses, but this cannot happen effectively without significant investment in skilling-up and developing capacity in primary care and in prioritising investment in social care and housing. The current incentives in the (health) system continue to reinforce investment and expenditure in acute hospitals. This must change since tackling the root cause of the issue should begin with the at risk individual living at home.

Nick Goodwin, senior fellow, the king’s fund is co-author of the new report case management. What it is and how it can best be implemented available at: