Case Management Training in Tayside

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Case Management Training in Tayside

• A Learning Process?

2
National Context

• Better Health, Better Care
• Changing Lives
• Care Management training framework
• Integrated Accessible Care
• Rehabilitation Framework

• Capability Framework for nursing
• Audit Scotland Report
• Other work e.g. Lanarkshire/NES
• SPARRA
• Open Space events
• English work- community matron
• Improvement programme

3
Local Context

• Ongoing,established care management
• Pilot work for case management
• Abertay course for case management
• Promises what we WILL deliver on in the next 12
  months

• Pathfinder site for integrated accessible care
• Host for National LTC Improvement programme
• And tensions/history and baggage

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LONG TERM CONDITIONSCURRENT POSITIONA
Fragmented Approach
Little or no prevention activity
Reactive
Task Orientated
Treatment Focussed
Few measurements related to holistic assessment
Patients problems treated in isolation from each
other
Illness Focussed
Uncoordinated
Various elements managed by various people
Little patient/ carer empowerment

• Pharmacy Issues
• - Hospital
• - GP
• Community
• Pharmacist

Multiple Hospital Admissions
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Case Management (A Holistic Approach)
Proactive anticipatory care
Patient/ carer empowerment
Clinical Management
Coordinated
Strategic direction
SMART
Right Place
Right People Multi-disciplinary
Quality of Life
6
Key Skills of Care/Case Management

• Co-ordination
• Collaboration
• Communication

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Benefits for people with long term conditions

• proactive care - anticipating need
• understanding of own condition
• support and building of confidence to self manage
  when appropriate
• co-ordination of services across agencies
• services as locally as possible

8
You asked for

• better coordination of services when you have a
  lot of people involved in your care

9
We promise

• To build on your existing care management
  arrangements which may be provided by the NHS and
  Local Authority. We will do this in a way that
  ensures that your care is better coordinated
  particularly when your needs are or become
  multiple and more complex

10
Partnership Approach

• Social Services
• Voluntary Agencies
• Specialist services
• AHPs
• Patients/Carers

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Training Issues?? (ones highlighted previously)

• Case Management
• Masters module in Case Management
• Advanced physical assessment
• Extended prescribing
• Motivational interviewing

• Care Management
• Care Management Framework
• Motivational Interviewing
• ARE THESE WHAT WE NEED???

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Better Health, Better Care

• Provide intensive case management based on
  individual care plans which coordinate the
  services provided by whichever individuals or
  organisations are most appropriate for the
  patients needs

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Over to Sheila!