Case management: What it is and how it can best be implemented

Key messages n Case management is an established tool in integrating services around the needs of individuals with long-term conditions. n It is a targeted, community-based and pro-active approach to care that involves case-finding, assessment, care planning, and care co-ordination. n The evidence for case management is mixed. However, where it is implemented effectively it has improved the experiences of users and carers, supporting better care outcomes, reducing the utilisation of hospital-based services, and enabling a more cost-effective approach to care. n The following factors are linked to the achievement of successful outcomes: n assigned accountability of an individual or team to the patients being case-managed n clarity about the role of the case managers and support to ensure they have the right clinical and managerial competencies n accurate case-finding to ensure interventions target patients with defined care needs n appropriate caseloads to ensure that patients are receiving optimum care n a single point of access for assessment and a joint care plan n continuity of care to reduce the risk of an unplanned admission to hospital n self-care, to empower patients to manage their own condition n joined-up health and social care services with professionals working to aligned financial incentives and in multidisciplinary teams n information systems that support communication, and data that is used pro-actively to drive quality improvements.