Case management to be used for people with chronic conditions
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《英国医生杂志》
A substantial overhaul of the care of patients with chronic diseases based on case management, coordinated by a new type of health professional—the community matron—was announced by the UK government last week.
John Reid, the health secretary, announced that the new system will provide a more structured approach to the provision of care by health and social services to people with chronic conditions, including diabetes, asthma, and arthritis in England and Wales. NHS and social care organisations will be expected to introduce case management from 2005 for vulnerable people with complex long term conditions. The aim is to treat patients sooner, nearer to home, and earlier in the course of their disease to improve their quality of life, reduce emergency hospital admissions, and, in some cases, prevent premature death. The target is to reduce inpatient emergency bed days by 5% by March 2008 using 2003-4 as the baseline.
The scheme is based on the NHS and social care long term conditions model, which can be adapted where necessary to meet specific local circumstances. The model, based on US systems including those developed by Evercare and Kaiser Permanente, but tailored to suit the NHS, works on the basis of providing personalised, systematic on-going support, coordinated by a case manager who assesses the patient抯 needs, develops a personalised care plan, monitors the patient regularly, initiates action—including prescribing if required—and liaises with other health professionals and social services, including hospitals if patients are admitted.
A report accompanying the announcement, Supporting People with Long Term Conditions, explained the overall aim: "We want to give patients the most intensive care in the least intensive setting. To do this we need to move away from a reactive, unplanned and episodic approach to care, particularly for those with complex conditions and high intensity needs."
The government expects that community matrons—specially trained nurses—will generally take on the role of case manager. Mr Reid said that the NHS aimed to have 3000 community matrons in place by March 2007. District nurses currently have the most similar role and are expected to make up a large proportion of the community matrons. They are likely to have caseloads of about 50-80 patients with complex needs and who require clinical intervention as well as care coordination. It will be up to trusts to decide whether community matrons work from a primary care trust, a general practice, or a hospital, but they will have to develop close working relationships with general practice, hospital wards, and local social services teams.
Mr Reid said, "As the number of people with long term illnesses increases, new ways of working must be developed to better identify when and where help and support is needed. There are already some excellent examples of long term conditions management, but we want to see this excellence spread across the country. The new model of care will provide the NHS with the blueprint to do just that."
A recent report from the King抯 Fund, a charitable foundation that researches healthcare policy, however, found little evidence from available research that a case management approach reduced hospital admissions or that it was cost effective. Ruth Hutt, visiting fellow in health policy for the King抯 Fund and one of the report抯 authors, thought that primary care trusts should be given flexibility to develop their own arrangements to improve care for those with long term conditions, taking into account existing local services and local needs. "Case management is unlikely to provide an off the shelf solution to achieving the required reductions in emergency admissions," she warned (BMJ 2004;329:1306, 4 Dec).
Concern also exists about how the new approach will work with existing arrangements. Dr Hamish Meldrum, chairman of the BMA抯 General Practitioner Committee, said that many GPs would take exception to the implication from the Department of Health that people with long term conditions currently went unmonitored and unmanaged. He warned that there was a danger that community matrons would duplicate the work that was already being done in primary care: "If the idea of community matrons is going to work, they have to be fully integrated into primary care, working with general practice and not at cross purposes."(London Susan Mayor)
John Reid, the health secretary, announced that the new system will provide a more structured approach to the provision of care by health and social services to people with chronic conditions, including diabetes, asthma, and arthritis in England and Wales. NHS and social care organisations will be expected to introduce case management from 2005 for vulnerable people with complex long term conditions. The aim is to treat patients sooner, nearer to home, and earlier in the course of their disease to improve their quality of life, reduce emergency hospital admissions, and, in some cases, prevent premature death. The target is to reduce inpatient emergency bed days by 5% by March 2008 using 2003-4 as the baseline.
The scheme is based on the NHS and social care long term conditions model, which can be adapted where necessary to meet specific local circumstances. The model, based on US systems including those developed by Evercare and Kaiser Permanente, but tailored to suit the NHS, works on the basis of providing personalised, systematic on-going support, coordinated by a case manager who assesses the patient抯 needs, develops a personalised care plan, monitors the patient regularly, initiates action—including prescribing if required—and liaises with other health professionals and social services, including hospitals if patients are admitted.
A report accompanying the announcement, Supporting People with Long Term Conditions, explained the overall aim: "We want to give patients the most intensive care in the least intensive setting. To do this we need to move away from a reactive, unplanned and episodic approach to care, particularly for those with complex conditions and high intensity needs."
The government expects that community matrons—specially trained nurses—will generally take on the role of case manager. Mr Reid said that the NHS aimed to have 3000 community matrons in place by March 2007. District nurses currently have the most similar role and are expected to make up a large proportion of the community matrons. They are likely to have caseloads of about 50-80 patients with complex needs and who require clinical intervention as well as care coordination. It will be up to trusts to decide whether community matrons work from a primary care trust, a general practice, or a hospital, but they will have to develop close working relationships with general practice, hospital wards, and local social services teams.
Mr Reid said, "As the number of people with long term illnesses increases, new ways of working must be developed to better identify when and where help and support is needed. There are already some excellent examples of long term conditions management, but we want to see this excellence spread across the country. The new model of care will provide the NHS with the blueprint to do just that."
A recent report from the King抯 Fund, a charitable foundation that researches healthcare policy, however, found little evidence from available research that a case management approach reduced hospital admissions or that it was cost effective. Ruth Hutt, visiting fellow in health policy for the King抯 Fund and one of the report抯 authors, thought that primary care trusts should be given flexibility to develop their own arrangements to improve care for those with long term conditions, taking into account existing local services and local needs. "Case management is unlikely to provide an off the shelf solution to achieving the required reductions in emergency admissions," she warned (BMJ 2004;329:1306, 4 Dec).
Concern also exists about how the new approach will work with existing arrangements. Dr Hamish Meldrum, chairman of the BMA抯 General Practitioner Committee, said that many GPs would take exception to the implication from the Department of Health that people with long term conditions currently went unmonitored and unmanaged. He warned that there was a danger that community matrons would duplicate the work that was already being done in primary care: "If the idea of community matrons is going to work, they have to be fully integrated into primary care, working with general practice and not at cross purposes."(London Susan Mayor)