Case management for elderly people in the communityBMJ 2007; 334 doi: https://doi.org/10.1136/bmj.39027.550324.47 (Published 04 January 2007) Cite this as: BMJ 2007;334:3
Reducing unplanned admissions to hospital is now a cornerstone of the commissioning plans of all primary care trusts as the national health service struggles with a rising tide of emergency admissions and a large financial deficit. The management and care of patients with long term conditions has become a priority; in particular, intervention to reduce the number of admissions of frail elderly patients with multiple chronic diseases. In this week's BMJ, Roland and colleagues report the impact of the Evercare approach to case management for elderly people living in the UK.1
In 2002 the Department of Health started to fund innovative projects aimed at transforming chronic care and improving care for people with long term conditions, to reduce emergency admissions and, presumably, costs. The decision to pilot the Evercare model in 10 primary care trusts (PCTs) was based in part on a study from the United States which used nurse practitioners in a managed care programme that was directed specifically at long stay nursing home residents.2 It found the incidence of admission to hospital was twice as high in control residents compared with Evercare residents over 15 months with a similar pattern for preventable admissions. The study estimated that using a nurse practitioner saved $103 000 (£54 000; €81 000) a year in hospital costs per nurse practitioner. Supporting this information were data from an Evercare project in Castlefields in the UK, run by UnitedHealth Group, that had not been subjected to peer review. The Department of Health was so certain that the project would be successful that it decided to create 3000 posts for community matrons across the NHS by 2008 to fill a role similar to the advanced nurse practitioner on the Evercare scheme.
The UK's Evercare programme was based on the US model for frail older people, combining elements of nurse led assessment and intensive case management, but in the community and not in a nursing home setting. It includes data analysis to identify high risk patients and changes in jobs, in particular to the new role of advanced practice nurse with extended generalised skills, and changing processes to organise care around the patient's needs rather than the current organisational boundaries.3 In the UK Evercare study the largest group of high risk patients was those with two or more emergency admissions in the previous year.3
Despite these advances, the current evidence base for intervention to improve chronic care is still weak. A review of 560 studies found a complex picture with some evidence that initiatives could enhance satisfaction with care, quality of life, and in some cases the use of health services. Evidence to support case management is sparse, and there is even less information on new models of commissioning services or on whether international programmes can be replicated in the UK.4 The Evercare model was particularly predicated on case management, which has been defined as “the process of planning, co-ordinating, managing and reviewing the care of an individual.”5 6 A recent review of case management by the King's Fund found weak evidence for case management in preventing admissions to acute care and no consistent effect on the use of emergency departments.6
In early 2005 an interim assessment of the Evercare programme in 2003-4 reported that its benefits were mostly in terms of quality of care.3 Half the patients and carers felt that quality of care had improved, with a quarter believing that care was “a lot” better. Among carers, 95% had seen an improvement in the patient's ability to cope. Patients felt that they were highly involved in decisions about their care and treatment. Among general practitioners, 80% said the role of advanced nurse practitioner helped in delivering more holistic patient centred care.
The interim report came to no conclusions on hospital admissions. The major criterion for entry to the programme had been a history of two or more emergency admissions in the previous year. Yet an analysis of hospital episode statistics for people aged 65 or over with a history of emergency admissions in England showed that, although those with two or more such admissions constituted 38% of admissions in the index year, they accounted for fewer than 10% of admissions in the following year and just over 3% five years later.7 The reasons for this are complex, but probably include deaths, planned admissions to long term care, further planned admissions (for example, for respite care), and “regression towards the mean” in surviving patients.3 7 8
This publication led to criticism about the failure to fund a properly controlled study beforehand; the cost and use of public funds (over £4m), with much of that going on travel, consultancy fees and training; and further national investment in a systematic case management approach across England without convincing evidence.9 10 Different outcomes might have been achieved if UnitedHealth Group had been able to hire its own nurses, and the maximum benefits might become apparent only in the second or third year.11 12
The study that was subsequently commissioned used a complex design to overcome the lack of a straightforward control group and compared various outcomes in the 62 Evercare practices with between 6960 and 7695 control practices across England.1 It found no effects on emergency admissions, emergency bed days, or mortality. Frustratingly, this adds little to help primary care trusts decide where to focus their commissioning efforts. The interim evidence of improved quality of care is welcomed by everyone who works with older people; on the other hand, the study does not support using nurse practitioners to reduce hospital admissions in patients who have had previous emergency admissions.
Identifying patients at risk and intervening before or during the first or second admission may still be an effective model of case management, but we need to research better predictors to judge which patients require intervention. From the point of view of a frail older person admitted in an emergency, comprehensive geriatric assessment as an inpatient, with ongoing control over medical recommendations, remains the proved intervention as it reduces mortality, reduces institionalisation rates, and improves functional status.13
Competing interests: None declared.