Integrated Case Management
Bringing together health professionals to improve patient outcomes
Encompass has been leading a trial into fully integrated case management (ICM), bringing together all health & wellbeing professionals to develop single care plans for those at the highest risk of developing long term conditions requiring acute care.
To ensure patients and the health service gain the most from ICM, the process first starts with identification of those patients who will benefit most from it.
In the pilot, this has focussed on patients with the highest likelihood of developing long-term or multiple health conditions which will limit their ability to live independently and place more pressure on acute health services as intervention is required.
Once patients are identified, a multi-disciplinary team (MDT) of professionals meet to review the individual’s current care arrangements. These teams will vary in each case, but typically will involve the GP, social worker, a mental health professional, community health nurse and a representative of Red Zebra, who are on hand to co-ordinate voluntary sector support and social prescribing.
From this, a single holistic assessment can be completed, reviewing all the different agencies’ care plans for the patient, identifying any gaps in the system, and developing a single care plan aimed at meeting the exact needs – both physical, mental and social – of that individual.
This allows for genuinely integrated care planning – not only ensuring the support provided to the patient is the right support for them, but also reducing the impact on acute and primary care services and making better use of resources.
Moreover, the ICM pilot has put these relevant health professionals around a table to discuss her case – not simply interpreting each others care plans, but discussing her needs and any concerns they have around her wellbeing.
Case Study: Valerie, 92
Valerie, who cares fulltime for her husband who suffers from dementia, had stopped carrying out normal day to day tasks, and had required trips to hospital after falling at home.
She openly admitted that she did not understand all the different agencies visiting her, and was, naturally, confused by the system and complexity of social worker visits, GP visits and other health professionals.
As a result of being part of the ICM trial, a number of very simple interventions have improved her life significantly.
* Valerie now has one daily visit from a carer – who is part of the integrated case management team and now has a relationship with all those involved in her care – from GP to social care staff and community nurses.
* A falls wrist band gives her confidence that, should she fall over at home, the right individual will immediately be notified and that any response is co-ordinated with her other care providers.
* A significant part of her fear was not being able to carry out daily tasks – which in turn affected her mental wellbeing. The simple addition of a zimmerframe trolley solved several issues – she is now confident moving around the house on her own, and can do so while performing day to day tasks and carrying things. This simple intervention has given her more confidence and she is now coping far better at home, reducing a deterioration in her mental health.
You can see Valerie’s story in her own words here.Valerie’s Story