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A new model of care for people who have long-term conditions

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VOL: 101, ISSUE: 03, PAGE NO: 28

Terry Hainsworth, BSc, RGN, is clinical editor, Nursing Times

Nurses have for some time been waiting for the new national service framework (NSF) for long-term conditions. This was announced in 2001 and publication was expected at the end of 2004.

The new document Supporting People with Long Term Conditions (DoH, 2005) outlines a model of care for this group of patients, which is to be led by new community matrons (Chatterjee, 2005). The document is a precursor to the NSF, which is now expected later this year and will focus on the needs of people with neurological disease and brain or spinal injury, as well as considering issues of relevance to a range of people with long-term conditions.

Management of long-term conditions

As many as 60 per cent of adults in England have a chronic health problem and some of these have multiple long-term conditions resulting in complex health care needs. As a result, a small number of patients and diseases account for a disproportionately large amount of health care use and hospital bed occupancy (National Primary and Care Trust Development Programme (NatPaCT), 2005). A strategy to improve the management of these conditions has the potential to both reduce hospital bed occupancy and improve the quality of life for this group of patients.

As part of the modernisation of the NHS, the DoH has been looking for innovative solutions to improve the efficiency of the NHS including improving management of long-term conditions. In February 2003 a group from the DoH and the NHS visited the US health care provider Kaiser Permanente to learn about the model it uses to manage care for people with long-term health problems and to identify lessons for the NHS. At the time there was scepticism about whether the NHS could learn anything from the US health care system where the basic principles of care provision are very different. However, the suggestion that the NHS could improve efficiency by learning from the US Kaiser Permanente model of care had already been made by Feachem et al (2002). They undertook a study to compare the costs and performance of the NHS with those of Kaiser Permanente’s integrated system for financing and delivering health services in California. The findings of this study challenged the widely held view that the NHS is efficient and that its inadequacies are mainly due to underinvestment.

Other US systems have also been investigated by the DoH in England, which invited Ovation’s Evercare programme to contribute its tools, techniques and expertise to help primary care trusts enhance the speed and certainty of achieving The NHS Plan and resulted in pilots in nine PCTs. Evercare is a health care improvement programme originally developed for the US government. It is reported to have improved quality while reducing costs of care for 60,000 vulnerable older people, and has reduced hospitalisations by 50 per cent among its patients in care facilities. This has been achieved while at the same time producing high family satisfaction and the same mortality outcomes compared with a control group (NatPaCT, 2004).

The model of care set out in the new document builds on the US models from Evercare and Kaiser Permanente.

The model of care

The aim of the model is to improve the health and quality of life of those who have long-term conditions by providing personalised, systematic and ongoing support. The document suggests that the model will help ensure effective joint working between all those involved in delivering care so patients experience a seamless journey through the health and social care systems.

The first step in implementing the model is for all patients who have a long-term condition to be identified. The level of care that they need is then mapped to the model at level one, two or three (Fig 1).

Case management

This third level of care is aimed at those people with long-term conditions who have frequent unplanned admissions in secondary care. The approach is to identify these patients as being at high risk and seek their agreement to be supported through case management. This involves developing a care plan setting out and agreeing health objectives and care needs for the person and the contributions that they and each care agency will make. The care plan should also include arrangements for emergency or contingency arrangements.

This case management approach has been successfully used for managing complex patient needs for some time in the UK (Hutt et al, 2004) and is very similar to the Evercare health care improvement programme. It is at this level of care that the new community matrons will be developing their role.

Disease-specific care management

This second level of care involves providing people who have a complex single need or multiple conditions with specialist services. Care at this level will be proactive following NSFs and National Institute for Clinical Excellence guidance for each specific condition.

It is suggested that in most cases support for this group of patients will come from multidisciplinary teams based in primary care with additional specialist advice from liaison workers such as diabetic liaison nurses where required.

Supported self-care

This first level of care is aimed at supporting people with long-term conditions to be able to perform self-care. This self-care and self-management are priorities for this model of care and are also a key pillar in the NHS improvement plan (DoH, 2004).

The document highlights that self-care and self- management are increasingly important in improving well-being, maintaining independence and quality of life for people with long-term conditions, and reducing their use of NHS services. The key actions recommended at this level are to develop a strategy to support self-care, making use of proven health education programmes such as the Expert Patient Programme (DoH, 2001) and dose adjustment for normal eating (Diabetes UK, 2005).

The document highlights that self-management is more than simply educating patients about their condition. It requires patients to play a central role in managing their own care and should empower them, and their family and carers, to handle their condition as effectively as possible.

Nursing implications

The document states that the immediate focus for implementation should be the introduction of case management for the most vulnerable people with complex long-term conditions. A key aspect of this is the employment of community matrons and the development of this new clinical role where nurses will work as case managers.

The nurse-led case management approach is already used to manage some people with long-term conditions. A study by the King’s Fund (Hutt et al, 2004) into evidence of the effectiveness of case management drawing on international studies found case management has the potential to reduce hospital admissions. However, it also highlighted that it is unclear what contributes to successful case management and how cost-effective these services are. It is therefore difficult to suggest which aspects of case management the new community matrons should focus on.

But evidence suggests that as well as providing clinical management of the long-term condition, nurse case managers also have a key role in coordinating services from other health and social care providers (Hutt et al, 2004).

The increasing importance placed on health education, patient choice and self-managed care that we have seen within recent guidance documents fits well with this new model of care. Providing health education and patient-centred care planning is the mainstay of the bottom two tiers of this care model. This may have an important role in improving management and reducing time spent in hospital care. However, developing relationships with patients to enable the negotiation of care plans and the concordance with treatment required to carry out this style of care is very time consuming. It also requires nurses to have good health promotion skills and be supported in innovative approaches such as using group work. There are a number of issues related to supporting self-care highlighted in the document, including:

- Ensuring that patients and carers have the skills and knowledge they need to handle their condition, adjust medication doses and handle flare-ups appropriately;

- Giving information that is accessible and meaningful;

- Empowering patients and their carers to manage and monitor their own condition;

- Ensuring patients have a consistent person to contact;

- Encouraging involvement in support networks for peer support and access to a knowledgeable patient.


The model of care must be used alongside existing NICE and NSF guidance as well as the new NSF for long-term conditions when it is published later this year. It offers a model of care with a high emphasis on self-management and involves proactive close management and collaboration in the care of the most vulnerable patients. It relies on the skills of nurses to assess patients and deliver appropriate care. Its success depends on the development of the new community matron role and the ability of nurses in primary care to engage their patients in self-management of their long-term conditions.

- This article has been double-blind peer-reviewed.

For related articles on this subject and links to relevant websites see

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